1114096872 NPI number — EL DORADO COMMUNITY SERVICE CENTER

Table of content: (NPI 1114096872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114096872 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:
Provider Other Organization Name Type Code:
6
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:
1114096872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2017
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 LINCOLN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90291-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-399-9883
Provider Business Practice Location Address Fax Number:
310-399-9678
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  960001025 , 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: CMM70719F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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