Provider Demographics
NPI:1053427302
Name:LOS BANOS COMMUNITY HOSPITAL
Entity type:Organization
Organization Name:LOS BANOS COMMUNITY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CENTRAL BUSINESS OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-572-7172
Mailing Address - Street 1:PO BOX 1870
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95353-1870
Mailing Address - Country:US
Mailing Address - Phone:209-569-7734
Mailing Address - Fax:209-569-7772
Practice Address - Street 1:520 I ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4211
Practice Address - Country:US
Practice Address - Phone:209-826-0591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL LOS BANOS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040000177261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM13998FMedicaid
CARHM13998FMedicaid