Healthcare Provider Details

I. General information

NPI: 1285100792
Provider Name (Legal Business Name): KEDREN COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 SOUTH AVALON BLVD
LOS ANGELES CA
90011
US

IV. Provider business mailing address

4211 SOUTH AVALON BLVD
LOS ANGELES CA
90011-5622
US

V. Phone/Fax

Practice location:
  • Phone: 323-432-5093
  • Fax:
Mailing address:
  • Phone: 323-432-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. EARLE CHARLES
Title or Position: CHIEF INFORMATION OFFICER
Credential: PH.D.
Phone: 323-432-5093