Healthcare Provider Details

I. General information

NPI: 1770737918
Provider Name (Legal Business Name): TOTAL FAMILY SUPPORT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 ATLANTIC AVE
LONG BEACH CA
90807-4515
US

IV. Provider business mailing address

830 S OLIVE ST
LOS ANGELES CA
90014-3006
US

V. Phone/Fax

Practice location:
  • Phone: 562-981-1501
  • Fax: 562-981-1502
Mailing address:
  • Phone: 213-213-0581
  • Fax: 213-213-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARINA VERKHOVSKY
Title or Position: DIRECTOR OF HR
Credential: MS
Phone: 213-213-0581