Basic Information
| Provider Information | |||||||||
| NPI: | 1740515428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCADP/AWAKENINGS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4139 PARAMOUNT BLVD SPC 63 | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906606168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629473835 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12322 CLEARGLEN AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906043872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622421077 | ||||||||
| FaxNumber: | 5629479895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2009 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | ZARATE | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADM ASSIST | ||||||||
| AuthorizedOfficialTelephone: | 5629473835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | 06-28-81 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | 237228780 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |
No ID Information.