Basic Information
| Provider Information | |||||||||
| NPI: | 1619106838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOHN'S WELL CHILD & FAMILY CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 S HOOVER ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900374045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
| FaxNumber: | 3235411601 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 S HOOVER ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900374045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
| FaxNumber: | 3235411601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2009 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | ADAMIK | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF HUMAN RESOUCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3235411604 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NP18546 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.