Healthcare Provider Details

I. General information

NPI: 1477255222
Provider Name (Legal Business Name): LOS ANGELES RENAISSANCE PROJECT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 05/20/2023
Certification Date: 05/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 W MADDOX ST
LONG BEACH CA
90810-2241
US

IV. Provider business mailing address

1216 W MADDOX ST
LONG BEACH CA
90810-2241
US

V. Phone/Fax

Practice location:
  • Phone: 562-578-9290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: MARCHAEL GORDON
Title or Position: CEO/FOUNDER
Credential:
Phone: 562-578-9290