1578608659 NPI number — EAST LA REMARKABLE CITIZENS ASSN

Table of content: (NPI 1578608659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578608659 NPI number — EAST LA REMARKABLE CITIZENS ASSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST LA REMARKABLE CITIZENS ASSN
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:
CASA CARLOS ICF DDH
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:
1578608659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3839 SELIG PLACE
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:
90031-3143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-223-3079
Provider Business Mailing Address Fax Number:
323-223-4684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8203 DISNEY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITTIER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90606-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-695-8786
Provider Business Practice Location Address Fax Number:
562-695-8786
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MADRID
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CEO PRESIDENT ADMINISTRATOR
Authorized Official Telephone Number:
323-223-3079

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , 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: LTC60563F . This is a "MEDICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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