Basic Information
| Provider Information | |||||||||
| NPI: | 1619456928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE MEMORIAL COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1828 E CESAR E CHAVEZ AVE STE 4100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239871200 | ||||||||
| FaxNumber: | 3239871212 | ||||||||
| Practice Location | |||||||||
| Address1: | 1828 E CESAR E CHAVEZ AVE STE 4100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239871200 | ||||||||
| FaxNumber: | 3239871212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | COAN | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3239871222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITE MEMORIAL COMMUNITY HEALTH CENTER | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.