Provider Demographics
NPI:1194735886
Name:LODI MEMORIAL HOSPITAL ASSOCIATION INC
Entity type:Organization
Organization Name:LODI MEMORIAL HOSPITAL ASSOCIATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:HARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-334-3411
Mailing Address - Street 1:PO BOX 3004
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1908
Mailing Address - Country:US
Mailing Address - Phone:209-334-3411
Mailing Address - Fax:209-339-7659
Practice Address - Street 1:1235 W VINE ST STE 20
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5109
Practice Address - Country:US
Practice Address - Phone:209-339-7625
Practice Address - Fax:209-339-7659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LODI MEMORIAL HOSPITAL ASSOCIATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-08
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000056261Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086833Medicaid
CAZZZ53356ZOtherBLUE SHIELD PROV GRP
CAZZZ13302ZMedicare PIN