MEDICARE: EDWIN RAY COLEMAN SR.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1558635789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWIN RAY COLEMAN SR.

Provider Business Mailing Address
First Line	:	3026 9 TH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028
Country	:	US
Telephone Number	:	323-461-2817
Fax Number	:	323-373-9786

Provider Business Practice Location Address
First Line	:	2614 CRENSHAW BLVD.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90016
Country	:	US
Telephone Number	:	310-230-5574
Fax Number	:	323-373-9786

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2012
Last Update Date	:	03/21/2012

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