Healthcare Provider Details

I. General information

NPI: 1023551900
Provider Name (Legal Business Name): FRED JEFFERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1448 E 142ND ST
COMPTON CA
90222-3702
US

IV. Provider business mailing address

1448 E 142ND ST
COMPTON CA
90222-3702
US

V. Phone/Fax

Practice location:
  • Phone: 310-763-1660
  • Fax: 310-763-0357
Mailing address:
  • Phone: 310-929-0738
  • Fax: 310-763-0357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DARRYL SEWELL
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 310-929-0738