=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003110982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL OF FAITH NON PROFIT ORGANIZATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2011
-----------------------------------------------------
Last Update Date | 02/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4996 LA SIERRA AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-500-2774
-----------------------------------------------------
Fax | 951-358-0762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4996 LA SIERRA AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-500-2774
-----------------------------------------------------
Fax | 951-358-0762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. LUIS ALBERTO CRUZ
-----------------------------------------------------
Credential | MFT
-----------------------------------------------------
Telephone | 951-500-2774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------