1073653630 NPI number — ST. JOHNS COMMUNITY HEALTH

Table of content: (NPI 1073653630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073653630 NPI number — ST. JOHNS COMMUNITY HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOHNS COMMUNITY HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073653630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 W 58TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90037-3632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-541-1660
Provider Business Mailing Address Fax Number:
323-541-1665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90007-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-749-0947
Provider Business Practice Location Address Fax Number:
213-749-7354
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANGIA
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
323-541-1660

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X , with the licence number: 960000214 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1073653630 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: FHC 70764F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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