NPIMap

Organization Active NPI

Providence Health System - Southern California

  • Skilled Nursing Facility
  • San Pedro, CA
National Provider Identifier
1770639809
Registry record updated May 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Practice address
1322 W 6TH St
San Pedro, CA 90732-3501
Phone
(310) 303-7496
Fax
(310) 303-7575
NPI assigned
Jan 25, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 9, 2025

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

1322 W 6TH St
San Pedro, CA 90732-3501

Mailing address

PO Box 31001-3017
Pasadena, CA 91110-3017

Other identifiers 1

IdentifierTypeStateIssuer
555848OtherCABLUE CROSS

Other names 1

  • Providence Little Company of Mary Sub Acute Care Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080625000373 CA Part A Provider - Skilled Nursing Facility 0042248536 Practice locations: San Pedro, CA

Skilled nursing facility certification: CCN 555848

Legal name
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Doing business as
PROVIDENCE LITTLE COMPANY OF MARY SUBACUTE CARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Mar 21, 2008
Last certification
Dec 6, 2024
Beds
125
Ownership / control type
Nonprofit Corporation
Multi-facility organization
Providence Health and Services
Organization structure
CorporationNon-profit
Incorporated
Dec 5, 1903 in CA
Enrollment address
1322 W 6TH St
San Pedro, CA 90732-3501
Nursing home name
PROVIDENCE LITTLE COMP OF MARY SUBACUTE CARE CTR
Affiliated entity
PROVIDENCE HEALTH & SERVICES

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

Other organizations with this tax ID 7

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

Ownership & related parties

All disclosed owners & managing parties 29

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
Operational/Managerial Control Jul 1, 2016
Richard S Blair Individual Corporate DirectorBoard Member Jul 1, 2016
Operational/Managerial Control Jul 1, 2016
Organization, San Diego, CA Medical staffing company Adp of the SNF Nov 14, 2025
Marvin O'Quinn Individual Corporate DirectorBoard Member Jan 1, 2024
Operational/Managerial Control Jan 1, 2024
Organization, Atlanta, GA Adp of the SNF Nov 14, 2025
Linda Buck Individual Corporate DirectorBoard Member Jan 1, 2025
Operational/Managerial Control Jan 1, 2025
Jason Kell Individual Operational/Managerial Control Jan 1, 2026
Adp of the SNF Jan 1, 2026
Organization, Carson, CA Medical provider/supplier, Management services company Adp of the SNF Nov 14, 2025
Providence Health & Services - Washington Organization, Renton, WA Non-profit Adp of the SNF Nov 14, 2025
Indirect Ownership Interest Sep 30, 2008
Providence Health System-Southern California Organization, Renton, WA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 26, 2007 100%
Operational/Managerial Control Jan 26, 2007
Adp of the SNF Jan 26, 2007
Direct Ownership Interest Jan 26, 2007 100%
Mary E Lyons Individual Corporate DirectorBoard Member Jul 1, 2016
Operational/Managerial Control Jul 1, 2016
Michael Ricks Individual Operational/Managerial Control Nov 5, 2023
Adp of the SNF Nov 5, 2023
Phyllis M Hughes Individual Corporate DirectorBoard Member Jul 1, 2016
Operational/Managerial Control Jan 1, 2014
Rogelio Riojas Individual Corporate DirectorBoard Member Jan 1, 2025
Operational/Managerial Control Jan 1, 2025
James Martin Individual Corporate OfficerAuthorized Official Jan 13, 2023
Operational/Managerial Control Jan 13, 2023
Adp of the SNF Jan 13, 2023
Charles Wallace Sorenson Individual Corporate DirectorBoard Member Jan 1, 2019
Operational/Managerial Control Jan 1, 2019
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary of Enrollments Dec 20, 2016
Operational/Managerial Control Dec 20, 2016
Adp of the SNF Dec 20, 2016
Gregory David Hoffman Individual Corporate OfficerChief Finance Executive Oct 1, 2020
Operational/Managerial Control Oct 1, 2020
Adp of the SNF Oct 1, 2020
Isiaah D Crawford Individual Corporate DirectorBoard Member Jan 1, 2012
Operational/Managerial Control Jan 1, 2012
Donna Markham Individual Corporate DirectorBoard Member Jan 1, 2024
Operational/Managerial Control Jan 1, 2024
Michael W Murphy Individual Corporate DirectorBoard Member Jan 1, 2020
Operational/Managerial Control Jan 1, 2020
Providence Health & Services Organization, Renton, WA Corporation, Non-profit Adp of the SNF Nov 14, 2025
Indirect Ownership Interest Jul 1, 2016
Mary Beth Kingston Individual Corporate DirectorBoard Member Sep 1, 2022
Operational/Managerial Control Sep 1, 2022
Bijan Ghatan Individual Operational/Managerial Control Apr 1, 2014
Adp of the SNF Apr 1, 2014
Eric D Sprunk Individual Corporate DirectorBoard Member Jan 1, 2022
Operational/Managerial Control Jan 1, 2022
Anna R Newsom Individual Corporate OfficerCorporate Secretary May 13, 2022
Operational/Managerial Control May 13, 2022
Adp of the SNF May 13, 2022
Darryl Elmouchi Individual Corporate OfficerPresident Apr 1, 2025
Operational/Managerial Control Apr 1, 2025
Adp of the SNF Apr 1, 2025
Karin Dufault Individual Corporate DirectorBoard Member Jan 1, 2025
Operational/Managerial Control Jan 1, 2025
Providence St. Joseph Health Organization, Renton, WA Corporation, Non-profit Adp of the SNF Nov 14, 2025
Indirect Ownership Interest Jul 1, 2016

Owners & managing parties with NPI records 2

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

Facilities with the same owner 13

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

View all 13

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

Care Compare: Nursing home

Medicare Care Compare
Listed as
Providence Little Comp of Mary Subacute Care CtrCCN 555848
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
4 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified
Mar 21, 2008
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
12598.2 residents per day on average
Chain
Providence Health & Services8 facilities in the chain
Penalties (3 years)
1Fines totaling $11,170

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0915830Little Co of Mary Sub Acute Care Ctr1322 West 6TH Street, San Pedro, CA 90732Certificate of waiverApr 7, 2027

NPI Registry JSON

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

{
    "created_epoch": "1169683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746748800000",
    "number": "1770639809",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1322 W 6TH ST",
            "city": "SAN PEDRO",
            "state": "CA",
            "postal_code": "907323501",
            "telephone_number": "310-303-7496",
            "fax_number": "310-303-7575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-25",
        "last_updated": "2025-05-09",
        "certification_date": "2025-05-09",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "555848",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Little Company of Mary Sub Acute Care Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Little Company of Mary Sub Acute Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Pedro, CA

Sources for this page

Verify at the official NPI Registry.