Healthcare Provider Details

I. General information

NPI: 1710185038
Provider Name (Legal Business Name): OKULI EAGLE'S NEST FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 N BULLIS RD SUITE 12
COMPTON CA
90221-1650
US

IV. Provider business mailing address

1315 N BULLIS RD SUITE 12
COMPTON CA
90221-1650
US

V. Phone/Fax

Practice location:
  • Phone: 310-609-2303
  • Fax: 310-609-2403
Mailing address:
  • Phone: 310-609-2303
  • Fax: 310-609-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number190520AN
License Number StateCA

VIII. Authorized Official

Name: MR. CHRISTIAN ODOEMENA
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 310-609-2303