Healthcare Provider Details

I. General information

NPI: 1285396622
Provider Name (Legal Business Name): DISADVANTAGED DISABLED MINORITIES FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20355 SHERMAN WAY CANOGA PARK
CANGO PK CA
91306
US

IV. Provider business mailing address

590 FARRINGTON HWY PMB 210-274
KAPOLEI HI
96707
US

V. Phone/Fax

Practice location:
  • Phone: 818-357-8541
  • Fax:
Mailing address:
  • Phone: 808-321-1807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. GLENN MICHAEL MCCLEARY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 808-321-1807