Basic Information
Provider Information | |||||||||
NPI: | 1245384296 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENKI HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 150 E OLIVE AVE | ||||||||
Address2: | STE. 203 | ||||||||
City: | BURBANK | ||||||||
State: | CA | ||||||||
PostalCode: | 915021846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189734899 | ||||||||
FaxNumber: | 8189734888 | ||||||||
Practice Location | |||||||||
Address1: | 160 S 7TH AVE | ||||||||
Address2: |   | ||||||||
City: | LA PUENTE | ||||||||
State: | CA | ||||||||
PostalCode: | 917463211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269618971 | ||||||||
FaxNumber: | 6269616685 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2007 | ||||||||
LastUpdateDate: | 05/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | URMER | ||||||||
AuthorizedOfficialFirstName: | CARL | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, C.O.O | ||||||||
AuthorizedOfficialTelephone: | 8189734899 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.H.S. | ||||||||
NPICertificationDate: | 05/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 000007360 | 05 | CA |   | MEDICAID | 000007253 | 05 | CA |   | MEDICAID | 000007258 | 05 | CA |   | MEDICAID | 000007452 | 05 | CA |   | MEDICAID | 000007472 | 05 | CA |   | MEDICAID | 000007977 | 05 | CA |   | MEDICAID | 000001912 | 05 | CA |   | MEDICAID | 000007255 | 05 | CA |   | MEDICAID | 000000215 | 05 | CA |   | MEDICAID | 000007173 | 05 | CA |   | MEDICAID | 000007254 | 05 | CA |   | MEDICAID |