Basic Information
| Provider Information | |||||||||
| NPI: | 1992125959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPT. OF VETERAN'S AFFAIRS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8629 IMPERIAL HWY | ||||||||
| Address2: | #125 | ||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902423953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623812495 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900731003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2014 | ||||||||
| LastUpdateDate: | 04/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | VALDEZ | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3104783711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | Y | Hospitals | Long Term Care Hospital |
No ID Information.