Healthcare Provider Details

I. General information

NPI: 1770800963
Provider Name (Legal Business Name): FIDELITY OUTPATIENT RECOVERY CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 E MANCHESTER BLVD SUITE B
INGLEWOOD CA
90301-1987
US

IV. Provider business mailing address

718 E MANCHESTER BLVD SUITE B
INGLEWOOD CA
90301-1987
US

V. Phone/Fax

Practice location:
  • Phone: 310-686-1794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. EME CHUKU NKUGBA
Title or Position: CEO
Credential:
Phone: 310-686-1794