Healthcare Provider Details

I. General information

NPI: 1760868418
Provider Name (Legal Business Name): NEW FAITH TRANSITIONAL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W ROSECRANS AVE
GARDENA CA
90249-2905
US

IV. Provider business mailing address

2233 W ROSECRANS AVE
GARDENA CA
90249-2905
US

V. Phone/Fax

Practice location:
  • Phone: 310-436-7760
  • Fax:
Mailing address:
  • Phone: 310-436-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20AA5193
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12545
License Number StateCA

VIII. Authorized Official

Name: ALICE BLACI
Title or Position: PRESIDENT
Credential:
Phone: 310-436-7760