Healthcare Provider Details

I. General information

NPI: 1861304271
Provider Name (Legal Business Name): MAURICE MAYNARD FOUNDATION INC WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 AVENUE H
BROOKLYN NY
11234-1441
US

IV. Provider business mailing address

3680 WILSHIRE BLVD
LOS ANGELES CA
90010-2707
US

V. Phone/Fax

Practice location:
  • Phone: 424-508-3827
  • Fax:
Mailing address:
  • Phone: 424-508-3827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. NEVON MAURICE WATSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 424-508-3827