Basic Information
| Provider Information | |||||||||
| NPI: | 1942281936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITE MEMORIAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVENTIST HEALTH WHITE MEMORIAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 E CESAR E CHAVEZ AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232685000 | ||||||||
| FaxNumber: | 3232655070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 E CESAR E CHAVEZ AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232685000 | ||||||||
| FaxNumber: | 3232655070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAFFOUL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3232685000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITE MEMORIAL MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 930000195 | CA | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | LTC55312F | 05 | CA | MEDICAID | ZZZA1920Z | 01 | CA | BLUE SHIELD | OTHER |