Basic Information
| Provider Information | |||||||||
| NPI: | 1104256601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL DORADO COMMUNITY SERVICE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EL DORADO -PALMDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26460 SUMMIT CIRCLE | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 E PALMDALE BLVD STE 129-131 | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619473333 | ||||||||
| FaxNumber: | 6615752397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2013 | ||||||||
| LastUpdateDate: | 05/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | SEANJAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 960001031 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.