1225294341 NPI number — SOUTHLAND OUTPATIENT RECOVERY CENTER

Table of content: (NPI 1225294341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225294341 NPI number — SOUTHLAND OUTPATIENT RECOVERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAND OUTPATIENT RECOVERY 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:
1225294341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90807-7144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-884-2220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 N LONG BEACH BLVD
Provider Second Line Business Practice Location Address:
1,2,& 3
Provider Business Practice Location Address City Name:
COMPTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90221-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-537-3396
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
OKORO
Authorized Official First Name:
SUNDAY
Authorized Official Middle Name:
I.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
562-884-2220

Provider Taxonomy Codes

  • Taxonomy code: 261QR0401X , with the licence number:  3027962 , 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)





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