Healthcare Provider Details

I. General information

NPI: 1669992152
Provider Name (Legal Business Name): CHLA TEACHING CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date: 07/07/2023
Reactivation Date: 08/02/2023

III. Provider practice location address

468 E SANTA CLARA ST
ARCADIA CA
91006-7228
US

IV. Provider business mailing address

4650 W SUNSET BLVD # MS 87
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-7177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDRE WOODS
Title or Position: DIRECTOR, PROVIDER NETWORK MGMT
Credential:
Phone: 323-361-4136