Healthcare Provider Details

I. General information

NPI: 1992967129
Provider Name (Legal Business Name): LOVE AND RESPECT YOUTH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4728 S WESTERN AVE
LOS ANGELES CA
90062-2320
US

IV. Provider business mailing address

4728 S WESTERN AVE
LOS ANGELES CA
90062-2320
US

V. Phone/Fax

Practice location:
  • Phone: 323-293-7388
  • Fax: 323-293-7805
Mailing address:
  • Phone: 323-293-7388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. KORESHA BABETTE BELL
Title or Position: AGENT OF RECORD
Credential:
Phone: 323-293-7805