Healthcare Provider Details

I. General information

NPI: 1619856788
Provider Name (Legal Business Name): LOS ANGELES WIDE COMMUNITY SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8611 CRENSHAW BLVD STE 203
INGLEWOOD CA
90305-2398
US

IV. Provider business mailing address

403 E 186TH ST
CARSON CA
90746-2119
US

V. Phone/Fax

Practice location:
  • Phone: 310-910-0076
  • Fax:
Mailing address:
  • Phone: 310-483-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. LALISA RUSK
Title or Position: OWNER
Credential:
Phone: 310-483-9279