Provider Demographics
NPI:1316938301
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:FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-339-7477
Mailing Address - Street 1:PO BOX 884577
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-4577
Mailing Address - Country:US
Mailing Address - Phone:209-334-3411
Mailing Address - Fax:209-339-7659
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:209-334-3411
Practice Address - Fax:209-339-7659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000056282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP40336FOtherCHDP
CAHSP40336FMedicaid
CAHSC00336FMedicaid
CAZZR00336FOtherCMSP DEPT OF HEALTH SVC
CAZZZC3903ZOtherBLUE SHIELD IN & OUTPT
CAZZR00336FOtherCMSP DEPT OF HEALTH SVC
CAHSP40336FOtherCHDP