Basic Information
Provider Information | |||||||||
NPI: | 1780928655 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR INTEGRATED FAMILY AND HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY CENTER BALDWIN PARK HIGH SCHOOL | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3900 NORTH PUENTE AVENUE | ||||||||
Address2: |   | ||||||||
City: | BALDWIN PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 917064428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269675103 | ||||||||
FaxNumber: | 6269671339 | ||||||||
Practice Location | |||||||||
Address1: | 560 S SAN JOSE AVE | ||||||||
Address2: |   | ||||||||
City: | COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917233144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269675103 | ||||||||
FaxNumber: | 6269671339 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2012 | ||||||||
LastUpdateDate: | 11/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NIGH | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6269661577 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTER FOR INTEGRATED FAMILY AND HEALTH SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.