1811032436 NPI number — FAMILY HEALTH CARE CENTERS OF GREATER LOS ANGELES, INC.

Table of content: (NPI 1811032436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811032436 NPI number — FAMILY HEALTH CARE CENTERS OF GREATER LOS ANGELES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY HEALTH CARE CENTERS OF GREATER LOS ANGELES, 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:
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:
1811032436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22310 WARDHAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAWAIIAN GARDENS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90716-1740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-420-2433
Provider Business Mailing Address Fax Number:
562-429-2053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22310 WARDHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAWAIIAN GARDENS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90716-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-420-2433
Provider Business Practice Location Address Fax Number:
562-429-2053
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VILLA
Authorized Official First Name:
RAQUEL
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
CEO / COO
Authorized Official Telephone Number:
562-928-9600

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  960001120 , 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: CMM70824F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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