Basic Information
| Provider Information | |||||||||
| NPI: | 1801227087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHCADA ROOSEVELT-ISHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1419 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164435473 | ||||||||
| FaxNumber: | 9164431732 | ||||||||
| Practice Location | |||||||||
| Address1: | 456 S MATHEWS ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900334326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232224591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2013 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9144435473 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 7884 | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |