Healthcare Provider Details

I. General information

NPI: 1164340626
Provider Name (Legal Business Name): WALLIS ANNENBERG HIGH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 S MAIN ST
LOS ANGELES CA
90037-1022
US

IV. Provider business mailing address

4000 S MAIN ST
LOS ANGELES CA
90037-1022
US

V. Phone/Fax

Practice location:
  • Phone: 323-235-6343
  • Fax:
Mailing address:
  • Phone: 323-235-6343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DOROTHY LEE
Title or Position: CFO
Credential:
Phone: 323-235-6343