Healthcare Provider Details

I. General information

NPI: 1508348608
Provider Name (Legal Business Name): LUPE CID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 VINE ST.
LOS ANGELES CA
90038
US

IV. Provider business mailing address

1224 VINE ST
LOS ANGELES CA
90038-1612
US

V. Phone/Fax

Practice location:
  • Phone: 323-769-6100
  • Fax:
Mailing address:
  • Phone: 323-769-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW116756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: