Basic Information
Provider Information | |||||||||
NPI: | 1720100159 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPECIAL SERVICE FOR GROUPS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SSG-PACIFIC CLINICS-APFC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 905 E 8TH ST | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900211848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2135531800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9353 E VALLEY BLVD | ||||||||
Address2: |   | ||||||||
City: | ROSEMEAD | ||||||||
State: | CA | ||||||||
PostalCode: | 917701934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262872988 | ||||||||
FaxNumber: | 6262871937 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2007 | ||||||||
LastUpdateDate: | 08/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HATANAKA | ||||||||
AuthorizedOfficialFirstName: | HERBERT | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2135531800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.