MEDICARE: L.A. COUNTY PROBATION DEPT.

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	251B00000X	Case Management Agency		CA

General Provider Information

NPI Number	:	1720306988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L.A. COUNTY PROBATION DEPT.

Provider Business Mailing Address
First Line	:	415 W OCEAN BLVD
Second Line	:	SUITE 100
City	:	LONG BEACH
State	:	CA
Zip	:	90802-4512
Country	:	US
Telephone Number	:	562-491-5834
Fax Number	:	562-435-8523

Provider Business Practice Location Address
First Line	:	415 W OCEAN BLVD
Second Line	:	SUITE 100
City	:	LONG BEACH
State	:	CA
Zip	:	90802-4512
Country	:	US
Telephone Number	:	562-491-5834
Fax Number	:	562-435-8523

Authorized Official
Title or Position	:	SUPERVISION DEPUTY PROBATION OFFICE
Name	:	MR. DAVID WONG
Credential	:
Telephone Number	:	562-491-5884

Provider Enumeration Date	:	05/12/2010
Last Update Date	:	05/12/2010

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