Basic Information
| Provider Information | |||||||||
| NPI: | 1679777486 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHNS WELL CHILD AND FAMILY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 W 27TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900073204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137490947 | ||||||||
| FaxNumber: | 2137497354 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W 27TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900073204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137490947 | ||||||||
| FaxNumber: | 2137497354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 08/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | TIGNER-WEEKES | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2137490947 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 13649 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.