1659642908 NPI number — SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM

Table of content: (NPI 1659642908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659642908 NPI number — SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM
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:
1659642908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2610 INDUSTRY WAY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LYNWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90262-4283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-631-8004
Provider Business Mailing Address Fax Number:
310-631-7830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14371 CLARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLFLOWER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90706-2901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-631-8004
Provider Business Practice Location Address Fax Number:
310-631-7830
Provider Enumeration Date:
01/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BARBOUR
Authorized Official First Name:
JACK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO / PRESIDENT
Authorized Official Telephone Number:
310-631-8004

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7824 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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