Basic Information
| Provider Information | |||||||||
| NPI: | 1417378597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEDREN COMMUNITY HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KEDREN COMMUNITY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
| FaxNumber: | 3234325186 | ||||||||
| Practice Location | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
| FaxNumber: | 3234325186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2013 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHARLES | ||||||||
| AuthorizedOfficialFirstName: | EARLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF INFORMATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3234325093 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550002516 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.