Providence Health System - Southern California
Organization Active NPI Home Health Agency · Burbank, CA
NPI 1164429684 · NPPES record last updated May 16, 2025
Key facts
- NPI
- 1164429684
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Home Health Agency 251E00000X
- License
- 980000499 (CA)
- Legal business name
- PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
- Practice address
- 250 E Olive Ave Ste 202
Burbank, CA 91502-1211 - Phone
- (818) 953-4451
- Fax
- (747) 229-2365
- NPI assigned
- Jun 30, 2005
- Organization subpart
- No
Authorized official
- Name
- Donald W Anderson Jr.
- Title
- Assistant Secretary for Enrollment
- Phone
- (425) 358-9786
Other NPIs with the same Medicare PAC ID 3
Corporate family (same tax ID) 4
Facilities with the same owner 140
Affiliated clinicians 16
-
Basem Fanous, MD
-
Donald J Huey, MD
-
Mary R Kombazdjian, M.D.
-
Daniel James Lewis, MD.
-
Angela Lowe, MD
-
Michael Lupo, MD
-
Mohammad Reza Nahed, MD FCCP
-
Michael C Nelson, MD.
-
Samuel M Nyamu, M.D.
-
Sarah Swanson, MD
-
Tam Thi Duc Te, MD.
-
Lou Ellen Wilson, MD
Medicare Care Compare: Home health agency
- Listed as
- Providence Home Health la County North
- Overall star rating
- ★★★★☆ 4 of 5
- Ownership
- Non-Profit
- Certified
- Jan 30, 1984
- Medicare certification status
- Active
- Services
- Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0920807 | Providence Health System - Southern California Dba | Certificate of waiver | Oct 9, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
Home health agency certification: CCN 057627
- Legal name
- PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
- Doing business as
- PROVIDENCE HOME HEALTH LA COUNTY NORTH
- Certification status
- Active
- Provider type (POS)
- Home health agency
- Participating since
- Jan 30, 1984
- Last certification
- Jun 14, 2018
- Ownership / control type
- Non-Profit
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 5, 1903 in CA
- Enrollment address
- 250 E Olive Ave
Ste 202
Burbank, CA 91502-1211
All disclosed owners & managing parties 25
| Name | Role | Since | Share |
|---|---|---|---|
| Diane L Hejna |
Corporate Director | Jul 1, 2016 | |
| Richard S Blair |
Corporate Director | Jul 1, 2016 | |
| Marvin O'Quinn |
Corporate Director |
Jan 1, 2024 | |
| Terri P Warren |
W-2 Managing Employee |
Nov 1, 2022 | |
| Carol Elizabeth Pacini |
Corporate Director |
Jan 1, 2021 | |
| Providence Health & Services - Washington |
Operational/Managerial Control | Sep 8, 2011 | |
| Providence Health System-Southern California |
5% Or Greater Direct Ownership Interest | Jul 1, 2016 | 100% |
| Erik Wexler |
Corporate Officer |
Jan 1, 2023 | |
| Mary E Lyons |
Corporate Director | Jul 1, 2016 | |
| Nicole Sikes |
W-2 Managing Employee |
Aug 22, 2022 | |
| Phyllis M Hughes |
Corporate Director | Jul 1, 2016 | |
| James Martin |
Corporate Officer |
Jan 13, 2023 | |
| Malisa J Westlund |
W-2 Managing Employee |
Mar 6, 2021 | |
| Charles Wallace Sorenson |
Corporate Director |
Jan 1, 2019 | |
| Michael D Robinson |
Operational/Managerial Control |
Jan 1, 2021 | |
| Donald Wayne Anderson |
Corporate Officer |
Dec 20, 2016 | |
| Gregory David Hoffman |
Corporate Officer |
Oct 1, 2020 | |
| Isiaah D Crawford |
Corporate Director | Jul 1, 2016 | |
| Donna Markham |
Corporate Director |
Jan 1, 2024 | |
| Michael W Murphy |
Corporate Director |
Jan 1, 2020 | |
| Providence Health & Services |
Other | Jul 1, 2016 | |
| Mary Beth Kingston |
Corporate Director |
Sep 1, 2022 | |
| Eric D Sprunk |
Corporate Director |
Jan 1, 2022 | |
| Anna R Newsom |
Corporate Officer |
May 13, 2022 | |
| Providence St. Joseph Health |
Other | Jul 1, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070202000134 | CA | Part a Provider - Home Health Agency | 0749190759 | Practice locations: Burbank, CA |
National Provider Directory
- Tax ID family
- St Joseph Hospital
Locations
3413 W Pacific Ave
Ste 201
Burbank, CA 91505
Phone (818) 953-4451
201 S Buena Vista St
Ste 125
Burbank, CA 91505
Phone (818) 847-4913
250 E Olive Ave
Ste 202
Burbank, CA 91502
Phone (818) 953-4451
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Home Health Agency | 251E00000X | 980000499 | CA | Yes |
Addresses
Primary practice location
250 E Olive Ave Ste 202
Burbank, CA 91502-1211
Mailing address
250 E Olive Ave Ste 202
Burbank, CA 91502-1211
Phone (818) 953-4451
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| HHA07627F | Medicaid | CA |
Other names
- PROVIDENCE HOME HEALTH LA COUNTY NORTH
- Providence Home Care
Other providers in Burbank, CA
- Promed Home Health Services, Inc.
- Promise ABA, LLC
- Sirinda Promlap
- Pronto Medical Supply Inc
- Prosperity Healthcare, Inc.
- Providence Health System - Southern California
- Providence Health System - Southern California
- Prudence Home Health Inc.
- Kristen Michele Prusa
- Darek Przebieda
All providers in Burbank, CA · Home Health Agency in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 16, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.