1700882156 NPI number — EL DORADO COMMUNITY SERVICE CENTER

Table of content: (NPI 1700882156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700882156 NPI number — EL DORADO COMMUNITY SERVICE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL DORADO COMMUNITY SERVICE CENTER
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:
INGLEWOOD MEDICAL & MENTAL HEALTH SERVICES
Provider Other Organization Name Type Code:
3
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:
1700882156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801809
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALENCIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91380-1809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-254-6630
Provider Business Mailing Address Fax Number:
661-254-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4450 W CENTURY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90304-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-671-0555
Provider Business Practice Location Address Fax Number:
310-674-5292
Provider Enumeration Date:
06/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
PRAMESH
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
661-254-6630

Provider Taxonomy Codes

  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 960000232 , 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: 1958 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMM70092F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EAP70092F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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