Basic Information
Provider Information | |||||||||
NPI: | 1700513660 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST JOHNS WELL CHILD AND FAMILY CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 808 W 58TH ST | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900373632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3235411600 | ||||||||
FaxNumber: | 3235411661 | ||||||||
Practice Location | |||||||||
Address1: | 1321 E. 1ST STREET | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900339003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3235411600 | ||||||||
FaxNumber: | 3235411661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2022 | ||||||||
LastUpdateDate: | 08/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GENIE | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: | SOCORRO | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
AuthorizedOfficialTelephone: | 3235411600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.