Healthcare Provider Details

I. General information

NPI: 1942523519
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CIVIC PLAZA DR SUITE 625
CARSON CA
90745-2243
US

IV. Provider business mailing address

5806 LEXINGTON AVE
LOS ANGELES CA
90038-2013
US

V. Phone/Fax

Practice location:
  • Phone: 310-549-4500
  • Fax:
Mailing address:
  • Phone: 213-706-5158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License NumberSP15837
License Number StateCA

VIII. Authorized Official

Name: MRS. VATTENE NADIA BAYNEY-FLEENER
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.A., CCC-SLP
Phone: 213-706-5158