Healthcare Provider Details

I. General information

NPI: 1154583979
Provider Name (Legal Business Name): DEPARTMENT OF VETERAN AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12635 S HALO DR
COMPTON CA
90221-1828
US

IV. Provider business mailing address

12635 S HALO DR
COMPTON CA
90221-1828
US

V. Phone/Fax

Practice location:
  • Phone: 310-608-1781
  • Fax:
Mailing address:
  • Phone: 310-608-1781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. JERMAINE LOVE WILLIAMS
Title or Position: RECREATION THERAPIST
Credential:
Phone: 310-478-3711