Healthcare Provider Details

I. General information

NPI: 1740424183
Provider Name (Legal Business Name): ST. JOSEPH CENTER HOMELESS SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 LINCOLN BLVD
VENICE CA
90291-2829
US

IV. Provider business mailing address

404 LINCOLN BLVD
VENICE CA
90291-2829
US

V. Phone/Fax

Practice location:
  • Phone: 310-399-6878
  • Fax: 310-399-1339
Mailing address:
  • Phone: 310-399-6878
  • Fax: 310-399-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICK MAIORINO
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 310-396-6468