Basic Information
| Provider Information | |||||||||
| NPI: | 1245486778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARCHIE | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | VON | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5101 S BROADWAY | ||||||||
| Address2: | APT. 303 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238024309 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093984383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2008 | ||||||||
| LastUpdateDate: | 08/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | ICAN818 | 01 | CA | LA COUNTY DMH | OTHER |