Basic Information
Provider Information | |||||||||
NPI: | 1588162028 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY FAMILY GUIDANCE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CFGC JEES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10929 SOUTH STREET, SUITE 208B | ||||||||
Address2: |   | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907035340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629245526 | ||||||||
FaxNumber: | 5629241040 | ||||||||
Practice Location | |||||||||
Address1: | 4443 LIVE OAK ST | ||||||||
Address2: |   | ||||||||
City: | CUDAHY | ||||||||
State: | CA | ||||||||
PostalCode: | 902014207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238902340 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2018 | ||||||||
LastUpdateDate: | 07/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SINKO | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | JAMES | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5629245526 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY FAMILY GUIDANCE CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 14662 | CA | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.