Basic Information
Provider Information | |||||||||
NPI: | 1689870024 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LANCASTER ADULT DAY HEALTH CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LANCASTER ADULT DAY HEALTH CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45104 10TH STREET WEST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | CA | ||||||||
PostalCode: | 93534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6619422391 | ||||||||
FaxNumber: | 6619026839 | ||||||||
Practice Location | |||||||||
Address1: | 858 W. JACKMAN | ||||||||
Address2: | SUITE #101 | ||||||||
City: | LANCASTER | ||||||||
State: | CA | ||||||||
PostalCode: | 93534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6619481228 | ||||||||
FaxNumber: | 6619488109 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2007 | ||||||||
LastUpdateDate: | 08/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COOK | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
AuthorizedOfficialTelephone: | 6619422391 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ANTELOPE VALLEY COMMUNITY CLINIC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X |   | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 261QA0600X | 060000691 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
ID | Type | State | Issuer | Description | ADU70254G | 05 | CA |   | MEDICAID | CMCSUBKMN | 05 | CA |   | MEDICAID |