Basic Information
| Provider Information | |||||||||
| NPI: | 1326177379 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SCHARP-COMPTON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2610 INDUSTRY WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106318004 | ||||||||
| FaxNumber: | 3106317830 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 INDUSTRY WAY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106274566 | ||||||||
| FaxNumber: | 3106274029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARBOUR | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3106318004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7303 | 01 | CA | PROVIDER NUMBER | OTHER |