Basic Information
Provider Information | |||||||||
NPI: | 1467738229 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOS ANGELES CENTERS FOR ALCOHOL AND DRUG ABUSE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WHITTIER CITY SCHOOL DISTRICT YOUTH SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11015 BLOOMFIELD AVE | ||||||||
Address2: |   | ||||||||
City: | SANTA FE SPRINGS | ||||||||
State: | CA | ||||||||
PostalCode: | 906704601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629062676 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5777 LOCKHEED AVE | ||||||||
Address2: |   | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906061030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629062676 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2011 | ||||||||
LastUpdateDate: | 10/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WIEWEL | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: | BRENDA | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5629062676 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LOS ANGELES CENTERS FOR ALCOHOL AND DRUG ABUSE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 190100BN | CA | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.