Provider Demographics
NPI:1194083824
Name:PROVIDENCE FACEY MEDICAL FOUNDATION
Entity type:Organization
Organization Name:PROVIDENCE FACEY MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5691
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:11333 SEPULVEDA BLVD
Practice Address - Street 2:SUITE 3200
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1116
Practice Address - Country:US
Practice Address - Phone:818-837-5776
Practice Address - Fax:818-837-5810
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FACEY MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-01
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical