Basic Information
| Provider Information | |||||||||
| NPI: | 1265719843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6666 GREEN VALLEY CIR | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902307068 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900131102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132130100 | ||||||||
| FaxNumber: | 2132130108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2011 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | LAMAR | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2132130100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMOTIONAL HEALTH ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.