Basic Information
| Provider Information | |||||||||
| NPI: | 1316039241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELDORADO COMMUNITY SERVICE CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EL DORADO-LAWNDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26460 SUMMIT CIRCLE (CORPORATE OFFICE) | ||||||||
| Address2: | SANTA CLARITA | ||||||||
| City: | CALIFORNIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913501809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4023 MARINE AVE | ||||||||
| Address2: | |||||||||
| City: | LAWNDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902601840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106759555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | PRAMESH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6613135503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QP2300X | 960000924 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | CMM70643F | 05 | CA | MEDICAID |