Basic Information
Provider Information | |||||||||
NPI: | 1518589266 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF LOS ANGELES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5555 FERGUSON DR STE 310-15 | ||||||||
Address2: |   | ||||||||
City: | COMMERCE | ||||||||
State: | CA | ||||||||
PostalCode: | 900225164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3239147773 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1359 N GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917241016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6264302900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2020 | ||||||||
LastUpdateDate: | 05/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OWENS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, EDIM | ||||||||
AuthorizedOfficialTelephone: | 2132888695 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF LOS ANGELES | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.