Basic Information
| Provider Information | |||||||||
| NPI: | 1952382947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE MEMORIAL MEDICAL CENTER | ||||||||
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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: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAFFOUL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3232685000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 930000195 | CA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 050103 | 01 | CA | BLUE CROSS | OTHER | HSC30103F | 05 | CA | MEDICAID | ZZZA1920Z | 01 | CA | BLUE SHIELD | OTHER |