Basic Information
| Provider Information | |||||||||
| NPI: | 1184962151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | XAVANNA | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CASE MANAGER | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 605 W OLYMPIC BLVD STE 550 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900151474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135531850 | ||||||||
| FaxNumber: | 2133833146 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 W OLYMPIC BLVD STE 550 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900151474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135531850 | ||||||||
| FaxNumber: | 2133833146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2013 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.