MEDICARE: DIOR SUNSET FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1336807072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIOR SUNSET FOUNDATION

Provider Business Mailing Address
First Line	:	516 W ESTHER ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-1529
Country	:	US
Telephone Number	:	424-312-9020
Fax Number	:

Provider Business Practice Location Address
First Line	:	516 W ESTHER ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-1529
Country	:	US
Telephone Number	:	424-312-9020
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CLIFFORD DION JACKSON JR.
Credential	:
Telephone Number	:	424-312-9020

Provider Enumeration Date	:	11/30/2021
Last Update Date	:	11/30/2021

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Directions to “DIOR SUNSET FOUNDATION ” Practice Location

Language	Start Address	Practice Location

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