Healthcare Provider Details

I. General information

NPI: 1770915597
Provider Name (Legal Business Name): AVIVA FAMILY AND CHILDREN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 CAMINO PALMERO
LOS ANGELES CA
90046
US

IV. Provider business mailing address

1701 CAMINO PALMERO ST
LOS ANGELES CA
90046-2902
US

V. Phone/Fax

Practice location:
  • Phone: 323-876-0550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number273152
License Number StateCA

VIII. Authorized Official

Name: IRA KRUSKAL
Title or Position: VICE PRESIDENT
Credential:
Phone: 323-876-0550