1508039728 NPI number — INDEPENDENCE COMMUNITY TREATMENT CLINIC

Table of content: (NPI 1508039728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508039728 NPI number — INDEPENDENCE COMMUNITY TREATMENT CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENCE COMMUNITY TREATMENT CLINIC
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:
Provider Other Organization Name Type Code:
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:
1508039728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19231 VICTORY BLVD
Provider Second Line Business Mailing Address:
SUITE 554
Provider Business Mailing Address City Name:
RESEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91335-6308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-776-1755
Provider Business Mailing Address Fax Number:
818-776-1657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 W AVENUE J
Provider Second Line Business Practice Location Address:
ROOMS E,G, H, FRONT OFFICE
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93534-3656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-776-1755
Provider Business Practice Location Address Fax Number:
818-776-1657
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRANZBURG
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
818-776-1755

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  960001358 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CMM70956F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196856000 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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