Provider Demographics
NPI:1699891697
Name:ST. FRANCIS MEDICAL CENTER- CCC
Entity type:Organization
Organization Name:ST. FRANCIS MEDICAL CENTER- CCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-900-8490
Mailing Address - Street 1:4390 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6237
Mailing Address - Country:US
Mailing Address - Phone:310-603-6949
Mailing Address - Fax:323-566-4984
Practice Address - Street 1:4390 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6237
Practice Address - Country:US
Practice Address - Phone:310-603-6949
Practice Address - Fax:323-566-4984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit