Healthcare Provider Details

I. General information

NPI: 1932344777
Provider Name (Legal Business Name): OUR HOUSE THEATRICAL LIVING & LEARNING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 E. DOMINGUEZ ST. SUITE B & C
CARSON CA
90746
US

IV. Provider business mailing address

1132 E. DOMINGUEZ ST. SUITE B & C
CARSON CA
90746
US

V. Phone/Fax

Practice location:
  • Phone: 310-763-4998
  • Fax: 310-886-3064
Mailing address:
  • Phone: 310-763-4998
  • Fax: 310-886-3064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberBUS.PERMIT NO.62287A
License Number StateCA

VIII. Authorized Official

Name: BARBARA W. SHALWAN
Title or Position: PRESIDENT-C.E.O.- DIRECTOR
Credential:
Phone: 310-763-4998