Basic Information
| Provider Information | |||||||||
| NPI: | 1568677235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL DORADO COMMUNITY SERVICE CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26460 SUMMIT CIR | ||||||||
| Address2: | SANTA CLARITA | ||||||||
| City: | CALIFORNIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546630 | ||||||||
| Practice Location | |||||||||
| Address1: | 5200 SAN GABRIEL PL SUITE B & C | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906602497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622221331 | ||||||||
| FaxNumber: | 5622221322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | PRAMESH | ||||||||
| AuthorizedOfficialMiddleName: | PRAKASH | ||||||||
| AuthorizedOfficialTitleorPosition: | SR V P | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 19AP | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 19-148 | 01 | CA | STATE NTP LICENSE | OTHER | 19AP | 01 | CA | ADPA | OTHER |