Healthcare Provider Details

I. General information

NPI: 1790050763
Provider Name (Legal Business Name): ANIMO LOCKE TECH CHARTER HIGH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E. 111TH STREET ROOM # 113 & 114
LOS ANGELES CA
90001
US

IV. Provider business mailing address

810 E. 111TH STREET ROOM # 113 & 114
LOS ANGELES CA
90001
US

V. Phone/Fax

Practice location:
  • Phone: 323-585-8985
  • Fax:
Mailing address:
  • Phone: 323-585-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number190622AN
License Number StateCA

VIII. Authorized Official

Name: MS. RONDA RENEE DIXON
Title or Position: EXECUTIVE DIRECTOR
Credential: JD
Phone: 323-988-3744