Provider Demographics
NPI:1023761715
Name:PROVIDENCE LITTLE CO. OF MARY HOSPITAL IN SAN PEDRO
Entity type:Organization
Organization Name:PROVIDENCE LITTLE CO. OF MARY HOSPITAL IN SAN PEDRO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PET TEAM
Authorized Official - Prefix:
Authorized Official - First Name:ARNULFO
Authorized Official - Middle Name:TARROBAGO
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:RN
Authorized Official - Phone:310-514-5480
Mailing Address - Street 1:1018 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4311
Mailing Address - Country:US
Mailing Address - Phone:310-936-6161
Mailing Address - Fax:
Practice Address - Street 1:1300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3505
Practice Address - Country:US
Practice Address - Phone:310-514-5480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA369004Medicaid