Basic Information
| Provider Information | |||||||||
| NPI: | 1356520779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNKNVETERANS ADMINISTRATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | |||||||||
| City: | SEPULVEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188959596 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21051 LASSEN ST | ||||||||
| Address2: | APARTMENT 78 | ||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913114273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194909556 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | BURTON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, COMMUNITY CARE | ||||||||
| AuthorizedOfficialTelephone: | 8188959596 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 261Q00000X-CLINIC/CE | CA | N | Ambulatory Health Care Facilities | Clinic/Center | 261QF0400X | 261QF0400X-CLINIC/CE | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 2865X1600X | 2865X1600X-MILITARY | CA | Y | Hospitals | Military Hospital | Military General Acute Care Hospital. Operational (Transportable) |
No ID Information.