Basic Information
Provider Information | |||||||||
NPI: | 1174803852 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELDORADO COMMUNITY SERVICE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 801809 | ||||||||
Address2: |   | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913801809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612546630 | ||||||||
FaxNumber: | 6612546644 | ||||||||
Practice Location | |||||||||
Address1: | 8207 WHITTIER BLVD | ||||||||
Address2: |   | ||||||||
City: | PICO RIVERA | ||||||||
State: | CA | ||||||||
PostalCode: | 906602521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626922522 | ||||||||
FaxNumber: | 5626950413 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2011 | ||||||||
LastUpdateDate: | 08/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHARMA | ||||||||
AuthorizedOfficialFirstName: | PRAMESH | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6612546630 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 1700882156 | 05 | CA |   | MEDICAID |