Basic Information
| Provider Information | |||||||||
| NPI: | 1356470397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CENTRAL HEALTH & REHABILITATION PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 INDUSTRY WAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106318004 | ||||||||
| FaxNumber: | 3106317830 | ||||||||
| Practice Location | |||||||||
| Address1: | 3741 STOCKER ST | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900085109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235962480 | ||||||||
| FaxNumber: | 3235962487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARBOUR | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3106318004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7555 | 01 | CA | PROVIDER NUMBER | OTHER |