Healthcare Provider Details

I. General information

NPI: 1952439093
Provider Name (Legal Business Name): ST. JOSEPH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HAMPTON DR
VENICE CA
90291-2623
US

IV. Provider business mailing address

204 HAMPTON DR
VENICE CA
90291-2623
US

V. Phone/Fax

Practice location:
  • Phone: 310-396-6468
  • Fax: 310-392-8402
Mailing address:
  • Phone: 310-396-6468
  • Fax: 310-392-8402

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: VA LECIA ADAMS KELLUM
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 310-396-6468