=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033533153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVALON-CARVER COMMUNITY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2014
-----------------------------------------------------
Last Update Date | 02/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4920 S. AVALON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-232-4391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4920 AVALON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90011-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-232-4391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. LAWRENCE RODGERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-232-4391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------