Healthcare Provider Details

I. General information

NPI: 1760247993
Provider Name (Legal Business Name): COMMUNITY OUTREACH FOR A BRIGHTER CALIFORNIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 E REGENT ST
INGLEWOOD CA
90301-1433
US

IV. Provider business mailing address

644 E REGENT ST
INGLEWOOD CA
90301-1433
US

V. Phone/Fax

Practice location:
  • Phone: 909-898-7665
  • Fax:
Mailing address:
  • Phone: 909-898-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LATISHA A SHEPHERD
Title or Position: OWNER
Credential:
Phone: 909-898-7665