Healthcare Provider Details

I. General information

NPI: 1306373964
Provider Name (Legal Business Name): CHINATOWN SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 W LAS TUNAS DR
SAN GABRIEL CA
91776-1134
US

IV. Provider business mailing address

767 N HILL ST STE 400
LOS ANGELES CA
90012-2381
US

V. Phone/Fax

Practice location:
  • Phone: 626-457-9618
  • Fax: 213-680-9427
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number960000220
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACK CHENG
Title or Position: CHIEF OPERATING OFFICER
Credential: JD, CHC, CHPC
Phone: 213-808-1709