Basic Information
| Provider Information | |||||||||
| NPI: | 1730624719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOHN'S WELL CHILD AND FAMILY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 326 W 23RD ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900072612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
| FaxNumber: | 3239249098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2016 | ||||||||
| LastUpdateDate: | 12/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | DOAN | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 3235411600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHARM.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 2724 | CA | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.