NPIMap

Organization Active NPI

Providence Health System - Southern California

  • Psychiatric Hospital Unit
  • San Pedro, CA
National Provider Identifier
1154349371
Registry record updated May 8, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
Legal business name
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Practice address
1300 W 7TH St
San Pedro, CA 90732-3505
Phone
(310) 832-3311
NPI assigned
Jul 17, 2006
Organization subpart
Yes
Parent organization
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 8, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X Primary

Addresses

Primary practice location

1300 W 7TH St
San Pedro, CA 90732-3505

Mailing address

PO Box 31001-3017
Pasadena, CA 91110-3017
Phone (310) 303-7496

Other identifiers 2

IdentifierTypeStateIssuer
05S078OtherCABLUE CROSS
HSM30078GMedicaidCA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070127000099 CA Part A Provider - Hospital 0042248536 Practice locations: San Pedro, CA

Hospital certification: CCN 05S078

Legal name
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Doing business as
PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
Organization structure
CorporationNon-profit
Incorporated
Dec 5, 1903 in CA
Enrollment address
1300 W 7TH St
San Pedro, CA 90732-3505
Hospital Psychiatric Unit
Hospital subgroups
Psychiatric unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Little Company of Mary - San Pedro8 organizations share this tax ID, including this one
Part of
Little Company of Mary - San Pedro

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Locations

150 N Robertson Blvd
Ste 150
Beverly Hills, CA 90211
Phone (310) 203-0222

357 E Carson St
Ste 102
Carson, CA 90745
Phone (310) 518-2737

1403 Lomita Blvd
Ste 305
Harbor City, CA 90710
Phone (310) 325-4344

14608 Hawthorne Blvd
Lawndale, CA 90260
Phone (310) 673-4900

3325 Palo Verde Ave
Ste 203
Long Beach, CA 90808
Phone (562) 377-1111

3742 Katella Ave
Ste 303
Los Alamitos, CA 90720
Phone (562) 296-8050

1520 San Pablo St
Los Angeles, CA 90033
Phone (323) 442-5849

10833 Le Conte Ave
#72140
Los Angeles, CA 90095
Phone (310) 206-2429

1200 Rosecrans Ave
Ste 110
Manhattan Beach, CA 90266
Phone (424) 220-4400

827 Deep Valley Dr
Ste 201
Rolling Hills Estates, CA 90274
Phone (310) 377-2202

1366 W 7th St
San Pedro, CA 90732
Phone (310) 548-0478

1360 W 6th St
Ste 185
San Pedro, CA 90732
Phone (310) 832-2697

800 S Pacific Ave
Ste A
San Pedro, CA 90731
Phone (310) 547-9991

18133 Ventura Blvd
Ste 102
Tarzana, CA 91356
Phone (424) 314-7695

3400 Lomita Blvd
Ste 101
Torrance, CA 90505
Phone (310) 539-4660

3333 Skypark Dr
Ste 160
Torrance, CA 90505
Phone (310) 517-9006

3275 Skypark Dr
Ste A
Torrance, CA 90505
Phone (310) 318-5333

21311 Madrona Ave
Ste 100C
Torrance, CA 90503
Phone (310) 792-4444

4201 Torrance Blvd
Ste 190
Torrance, CA 90503
Phone (310) 543-2521

23451 Madison St
Ste 300
Torrance, CA 90505
Phone (310) 375-9994

3330 Lomita Blvd
Ste 2681
Torrance, CA 90505

23365 Hawthorne Blvd
Ste 101
Torrance, CA 90505
Phone (310) 326-0202

1231 N Avalon Blvd
Wilmington, CA 90744
Phone (310) 835-5000

Ownership & related parties

All disclosed owners & managing parties 25

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Diane L Hejna Individual Corporate DirectorBoard Member Jul 1, 2016
Richard S Blair Individual Corporate DirectorBoard Member Jul 1, 2016
Marvin O'Quinn Individual Corporate DirectorBoard Member Jan 1, 2024
Linda Buck Individual Corporate DirectorBoard Member Jan 1, 2025
Jason Kell Individual W-2 Managing EmployeeFinancial Executive Jan 1, 2026
Providence Health & Services - Washington Organization, Renton, WA Operational/Managerial Control Jun 3, 2009
Providence Health System-Southern California Organization, Renton, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jun 3, 2009 100%
Mary E Lyons Individual Corporate DirectorBoard Member Jul 1, 2016
Michael Ricks Individual W-2 Managing EmployeeCeo Nov 5, 2023
Phyllis M Hughes Individual Corporate DirectorBoard Member Jan 1, 2014
Rogelio Riojas Individual Corporate DirectorBoard Member Jan 1, 2025
James Martin Individual Corporate OfficerAuthorized Official Jan 13, 2023
Charles Wallace Sorenson Individual Corporate DirectorBoard Member Jan 1, 2019
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary of Enrollments Dec 20, 2016
Gregory David Hoffman Individual Corporate OfficerPresident/Ceo & Treasurer Oct 1, 2020
Isiaah D Crawford Individual Corporate DirectorBoard Member Feb 1, 2012
Donna Markham Individual Corporate DirectorBoard Member Jan 1, 2024
Michael W Murphy Individual Corporate DirectorBoard Member Jan 1, 2020
Providence Health & Services Organization, Renton, WA Corporation, Non-profit Other Jul 1, 2016
Mary Beth Kingston Individual Corporate DirectorDirector Sep 1, 2022
Eric D Sprunk Individual Corporate DirectorDirector Jan 1, 2022
Anna R Newsom Individual Corporate OfficerCorporate Secretary May 13, 2022
Darryl Elmouchi Individual Corporate OfficerPresident/Ceo Apr 1, 2025
Karin Dufault Individual Corporate DirectorBoard Member Jan 1, 2025
Providence St. Joseph Health Organization, Renton, WA Corporation, Non-profit Other Jul 1, 2016

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 140

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 140

Practitioners & affiliated clinicians

Practitioners 332

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 332

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746662400000",
    "number": "1154349371",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-3017",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911103017",
            "telephone_number": "310-303-7496",
            "fax_number": "310-303-7496"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 W 7TH ST",
            "city": "SAN PEDRO",
            "state": "CA",
            "postal_code": "907323505",
            "telephone_number": "310-832-3311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA",
        "enumeration_date": "2006-07-17",
        "last_updated": "2025-05-08",
        "certification_date": "2025-05-08",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "05S078",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HSM30078G",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in San Pedro, CA

Sources for this page

Verify at the official NPI Registry.