Basic Information
| Provider Information | |||||||||
| NPI: | 1114096872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL DORADO COMMUNITY SERVICE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VENICE MEDICAL & MENTAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801809 | ||||||||
| Address2: | |||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913801809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 717 LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103999883 | ||||||||
| FaxNumber: | 3103999678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | SEANJAY | ||||||||
| AuthorizedOfficialMiddleName: | RAMANAND | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 960001025 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | CMM70719F | 05 | CA | MEDICAID |