1619742244 NPI number — GRAPE STREET COMMUNITY RESTORATION INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619742244 NPI number — GRAPE STREET COMMUNITY RESTORATION INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAPE STREET COMMUNITY RESTORATION INC.
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:
1619742244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10139 BEACH ST APT 26A-3
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:
90002-2978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-801-6071
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10139 BEACH ST APT 26A-3
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:
90002-2978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-801-6071
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RANDOLPH
Authorized Official First Name:
SEBASTIAN
Authorized Official Middle Name:
DEE
Authorized Official Title or Position:
CLINICAL MENTAL HEALTH COUNSELOR
Authorized Official Telephone Number:
602-736-7383

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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