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DSH050078A PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO (Active)
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Main Details
Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
Subdivision Name
Crisis Stabilization Unit - Psychiatry
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050078A
Medicare Provider Number
050078
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
7/13/2018
Participating Start Date
10/1/2018
Participating Approval Date
7/31/2018
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
1386 W 7th Street
san pedro, CA 90732
Billing Address
Providence LCMMC San Pedro
1300 W 7TH STREET
san pedro, CA 90732
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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