Covered Entity Details

DSH050353 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE (Active) - information as of 6/17/2025 2:31:19 AM

Main Details

Name

PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050353

Medicare Provider Number

050353

Additional Details

Current Program Status

Active

Registration Date

2/22/2007

Participating Start Date

4/1/2007

Participating Approval Date

2/23/2007

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Providence Health & Services Little Company of Mary Medical Centers San Pedro and Torrance
John Fleming Goeders, Chief Financial Officer
(310) 829-8411

Primary Contact

Providence Little Company of Mary Medical Center
Muno Bholat, Director of Pharmacy
(310) 303-5722

Addresses

Street Address

4101 TORRANCE BLVD.
TORRANCE, CA 90503

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
6/19/2009- UPDATED ENTITY NAME (WAS LITTLE COMPANY OF MARY HOSPITAL) AND CONTACT PERSON INFO.; 8/7/08-DOC SUBMITTED TO CONFIRM ELIG DSH ADJ PERCENTAGE	06/19/2009

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	HSC30353	1902844988,1821010315

Shipping Addresses

Shipping Address 1

PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TO
4101 Torrance blvd
Torrance, CA 90503

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACARIAHEALTH PHARMACY #11, INC	1311 W SAM HOUSTON PKWY N STE 130		HOUSTON	TX	77043-4015	01/07/2019	04/01/2019	09/28/2021	09/28/2021
Contract Detail	ACARIAHEALTH PHARMACY #13, INC	3302 GARFIELD AVE.		COMMERCE	CA	90040-3102	01/07/2019	04/01/2019	09/28/2021	09/28/2021
Contract Detail	ACARIAHEALTH PHARMACY #13, INC	3302 GARFIELD AVE.		COMMERCE	CA	90040-3102	01/07/2019	04/01/2019	09/28/2021	09/28/2021
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	08/07/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	08/07/2017	10/01/2017	01/01/2018	01/09/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	08/07/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	08/07/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	08/07/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	08/07/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	08/07/2017	10/01/2017		10/01/2017
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	08/11/2017	10/01/2017		10/01/2017
Contract Detail	BIOPLUS SPECIALTY INFUSION CA, LLC	19110 VAN NESS AVE.		TORRANCE	CA	90501	07/15/2019	10/01/2019	11/18/2024	11/18/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY CA	7373 LINCOLN WAY		GARDEN GROVE	CA	92841	07/15/2019	10/01/2019	11/18/2024	11/18/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	07/15/2019	10/01/2019	11/18/2024	11/18/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	07/15/2019	10/01/2019	11/18/2024	11/18/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	08/11/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/19/2021	07/01/2021		07/01/2021
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	7358 S W DURHAM ROAD	PORTLAND	OR	97224	08/11/2017	10/01/2017	04/09/2021	04/19/2021
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	14935 NE 87TH STREET SUITE 101	REDMOND	WA	98052-3474	08/11/2017	10/01/2017	04/09/2021	04/19/2021
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	5511 E 3RD AVE	SPOKANE VALLEY	WA	99212-0726	08/11/2017	10/01/2017	04/09/2021	04/19/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/19/2021	07/01/2021		07/01/2021
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	01/20/2017	04/01/2017	07/01/2017	10/09/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/06/2017	07/01/2017	04/20/2021	04/20/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	08/09/2017	10/01/2017	04/20/2022	04/20/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF PHOENIX,	DIPLOMAT SPECIALTY PHARMACY	485 N. JUNIPER DR	CHANDLER	AZ	85226	07/12/2019	10/01/2019	10/01/2021	10/01/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	07/16/2017	10/01/2017	07/12/2019	07/12/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05809	4775 W. ROSECRANS AVE.	HAWTHORNE	CA	90250	01/18/2021	01/21/2021		01/21/2021
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08868	5020 WEST 190TH STREET	TORRANCE	CA	90503	01/18/2021	01/21/2021		01/21/2021
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09477	5399 WEST CENTINELA AVENUE	LOS ANGELES	CA	90045	01/18/2021	01/21/2021		01/21/2021
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	07/15/2019	10/01/2019	11/18/2024	11/18/2024
Contract Detail	KROGER SPECIALTY PHARMACY FL 2	6435 HAZELTINE NATIONAL DR STE 140		ORLANDO	FL	32822-5156	07/15/2019	10/01/2019	06/30/2022	06/30/2022
Contract Detail	KROGER SPECIALTY PHARMACY INC	KROGER SPECIALTY PHARMACY CA 3	1821 KAISER AVE	IRVINE	CA	92614-5707	01/13/2021	01/21/2021	11/18/2024	11/18/2024
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/04/2018	07/01/2018	04/20/2022	04/20/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/04/2018	07/01/2018	04/20/2022	04/20/2022
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/10/2020	04/01/2020	04/20/2022	04/20/2022
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	04/04/2018	07/01/2018	01/09/2020	01/10/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	01/09/2018	04/01/2018	04/20/2021	04/20/2021
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	08/11/2017	10/01/2017		10/01/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	08/11/2017	10/01/2017		10/01/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/19/2021	07/01/2021		07/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/19/2021	07/01/2021		07/01/2021
Contract Detail	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFO	DBA PROVIDENCE LITTLE COMPANY OF MARY ME	1300 W 7TH ST SAN PEDRO PHARMACY	SAN PEDRO	CA	90732	07/15/2019	10/01/2019		10/01/2019
Contract Detail	SPECIALTY THERAPEUTIC CARE	1311 W SAM HOUSTON PKWY N STE 150		HOUSTON	TX	77043-4015	01/07/2019	04/01/2019	09/28/2021	09/28/2021
Contract Detail	WALGREEN CO	DBA: WALGREENS #10069	11983 HAWTHORNE BLVD	HAWTHORNE	CA	90250	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #06496	2321 HAWTHORNE BLVD.	REDONDO BEACH	CA	90278	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07481	22930 S WESTERN AVE	TORRANCE	CA	90501	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16368	3745 S LA BREA AVE STE C & D	LOS ANGELES	CA	90016	04/19/2017	07/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16561	1001 W CARSON ST STE K	TORRANCE	CA	90502	10/16/2018	01/01/2019	04/20/2021	04/20/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15190	1399 ROXBURY DR	LOS ANGELES	CA	90035	10/16/2018	01/01/2019	04/20/2021	04/20/2021
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/20/2017	04/01/2017	01/01/2018	01/09/2018
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/09/2017	01/01/2018	04/20/2021	04/20/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/20/2017	04/01/2017	04/20/2021	04/20/2021
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	10/09/2017	01/01/2018	04/20/2021	04/20/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050353A	Child	DSH	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	OUTPATIENT REHABILITATION / Physical Therapy	21135 HAWTHORNE BLVD	TORRANCE	CA	Active
DSH050353B	Child	DSH	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	LCMH Med Therapy Mgmt Clinic - Phamacotherapy	4101 TORRANCE BLVD	TORRANCE	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/31/2023 6:51:51 AM	8/23/2024 8:31:55 PM	8/23/2024 8:31 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 6:27:01 AM	8/31/2023 6:51:51 AM	8/31/2023 6:51 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 5:39:36 PM	8/30/2022 6:27:01 AM	8/30/2022 6:27 AM
Addresses	Shipping Address	Delete	Change Request	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TO 20555 Earl Street Torrance, CA 90503		12/1/2021 1:53 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 6:31:03 PM	9/9/2021 5:39:36 PM	9/9/2021 5:39 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1821010315	9/10/2020 6:31 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2020 6:31 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/10/2020 6:31 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 10:52:45 AM	9/10/2020 6:31:03 PM	9/10/2020 6:31 PM
Contacts	Authorizing Official	Update	AO Change Request	Wang, Ted CFO LCM Torrance and San Pedro 3103036114	Goeders, John Fleming Chief Financial Officer Providence Health & Services Little Company of Mary Medical Centers San Pedro and Torrance 3108298411	7/7/2020 8:00 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 11:02:55 AM	8/26/2019 10:52:45 AM	8/26/2019 10:52 AM
Details	Last Recertification Date	Update	Recertification	11/7/2017 8:52:02 AM	8/16/2018 11:02:55 AM	8/16/2018 11:02 AM
Details	Last Recertification Date	Update	Recertification	8/11/2016 12:00:00 AM	11/7/2017 8:52:02 AM	11/7/2017 8:52 AM
Contacts	Authorizing Official	Update		Wang, Ted CFO 3103036114	Wang, Ted CFO LCM Torrance and San Pedro 3103036114	10/9/2017 5:15 PM
Contacts	Primary Contact	Update		Bholat, Muno Director of Pharmacy 3103035722	Bholat, Muno Director of Pharmacy Providence Little Company of Mary Medical Center 3103035722	10/9/2017 4:08 PM
Contacts	Authorizing Official	Update		OLNEY, GARRY COO 3103036103	Wang, Ted CFO 3103036114	8/11/2017 5:12 PM
Contacts	Primary Contact	Insert			Bholat, Muno Director of Pharmacy 3103035722	6/22/2017 10:58 AM
Addresses	Main Address	Insert			4101 TORRANCE BLVD. TORRANCE, CA 90503	6/22/2017 10:58 AM
Addresses	Shipping Address	Insert			PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TO 20555 Earl Street Torrance, CA 90503	6/22/2017 10:58 AM
Addresses	Shipping Address	Insert			PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TO 4101 Torrance blvd Torrance, CA 90503	6/22/2017 10:58 AM
Contacts	Authorizing Official	Insert			OLNEY, GARRY COO 3103036103	5/9/2017 12:00 PM
Details	Last Recertification Date	Update		8/20/2015 12:00:00 AM	8/11/2016 12:00:00 AM	8/11/2016 11:54 AM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/20/2015 12:00:00 AM	8/20/2015 7:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/3/2014 9:14 PM
Medicaid Billing	Medicaid: Number	Insert			HSC30353	9/3/2014 9:14 PM
Medicaid Billing	Medicaid: State	Insert			CA	9/3/2014 9:14 PM
Details	Last Recertification Date	Update		8/29/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 8:49 PM
Details	Entity Name	Update		PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	9/25/2013 6:20 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/29/2013 12:00:00 AM	8/29/2013 1:35 PM
Medicaid Billing	NPI: Number	Insert			1902844988	5/14/2012 8:25 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 8:25 AM
Details	Last Recertification Date	Insert				6/19/2009 11:10 AM
Details	Grant Number	Insert				6/19/2009 11:10 AM
Details	340B ID	Insert			DSH050353	6/19/2009 11:10 AM
Details	Is Authorizing Official EHB Data	Insert				6/19/2009 11:10 AM
Dates	Last Date That 340B Drugs Purchased	Insert				6/19/2009 11:10 AM
Details	Medicare Provider Number	Insert			050353	6/19/2009 11:10 AM
Details	Entity Name	Insert			PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	6/19/2009 11:10 AM
Details	Program Code	Insert			DSH	6/19/2009 11:10 AM
Details	Entity Subname	Insert				6/19/2009 11:10 AM
Dates	Participating Approval Date	Insert			2/23/2007 12:00:00 AM	6/19/2009 11:10 AM
Details	State	Insert			Active	6/19/2009 11:10 AM
Dates	Registration Date	Insert			2/22/2007 12:00:00 AM	6/19/2009 11:10 AM
Dates	Signed By Date	Insert			11/30/2006 12:00:00 AM	6/19/2009 11:10 AM
Dates	Start Date	Insert			4/1/2007 12:00:00 AM	6/19/2009 11:10 AM
Terminations	Termination Comments	Insert				6/19/2009 11:10 AM
Terminations	Termination Date	Insert				6/19/2009 11:10 AM
Terminations	Termination Effective Date	Insert				6/19/2009 11:10 AM
Terminations	Termination Reason	Insert				6/19/2009 11:10 AM
Details	Comments Public	Insert			6/19/2009- UPDATED ENTITY NAME (WAS LITTLE COMPANY OF MARY HOSPITAL) AND CONTACT PERSON INFO.; 8/7/08-DOC SUBMITTED TO CONFIRM ELIG DSH ADJ PERCENTAGE	6/19/2009 11:10 AM