Healthcare Provider Details

I. General information

NPI: 1033243753
Provider Name (Legal Business Name): ARTHUR ASHE STUDENT HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WEST WOOD PLAZA
LOS ANGELES CA
90024-1703
US

IV. Provider business mailing address

BOX 951703
LOS ANGELES CA
90024-1703
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-7283
  • Fax: 310-267-1996
Mailing address:
  • Phone: 310-794-7283
  • Fax: 310-267-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number380579
License Number StateCA

VIII. Authorized Official

Name: MR. SAM BROWN
Title or Position: HIIPA COORDINATOR
Credential:
Phone: 310-206-6356