Healthcare Provider Details

I. General information

NPI: 1053508739
Provider Name (Legal Business Name): DELORES ICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4023 MARINE AVE
LAWNDALE CA
90260-1840
US

IV. Provider business mailing address

26460 SUMMIT CIR
SANTA CLARITA CA
91350-2991
US

V. Phone/Fax

Practice location:
  • Phone: 310-675-9555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: