Healthcare Provider Details

I. General information

NPI: 1780204537
Provider Name (Legal Business Name): FT. KNOX SUPPORTIVE HOUSING FOR HOMELESS VETERANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 W TERRACE ST
ALTADENA CA
91001-4706
US

IV. Provider business mailing address

321 N PASS AVE # 105
BURBANK CA
91505-3859
US

V. Phone/Fax

Practice location:
  • Phone: 323-386-1387
  • Fax:
Mailing address:
  • Phone: 323-386-1387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: LATONDA KNOX
Title or Position: CEO/CASE MANAGER
Credential: RN , ADMIN
Phone: 323-386-1387