Healthcare Provider Details

I. General information

NPI: 1417378597
Provider Name (Legal Business Name): KEDREN COMMUNITY CARE CLINIC - A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD BLDG A
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

4211 AVALON BLVD BUILDING A
LOS ANGELES CA
90011-5622
US

V. Phone/Fax

Practice location:
  • Phone: 323-234-0616
  • Fax: 323-515-7006
Mailing address:
  • Phone: 323-233-0425
  • Fax: 323-432-5186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550002516
License Number StateCA

VIII. Authorized Official

Name: MR. JASON ALEXANDER WARNER
Title or Position: CHIEF INFORMATION OFFICER
Credential: MHA, MBA
Phone: 323-515-7010