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General NPI Number Information
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NPI Number | 1043668023
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF HEALTH SERVICES
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Dates
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Enumeration Date | 05/31/2016
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Last Update Date | 05/31/2016
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Provider Practice Location Address
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Address Line | 450 BAUCHET ST MSB ----ROOM E873
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City | LOS ANGELES
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State | CA
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Zip | 90012-2907
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Country | US
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Telephone | 323-568-4550
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Fax |
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Provider Business Mailing Address
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Address Line | 450 BAUCHET ST MSB ----ROOM E873
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City | LOS ANGELES
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State | CA
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Zip | 90012-2907
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Country | US
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Telephone | 323-568-4550
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER WHCNP
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Name | MICHELE M GREEN
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Credential | BSN, PHN, MSN, NP
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Telephone | 310-702-4285
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2400X
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Taxonomy Name | Prison Health Clinic/Center
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License Number | 14185
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License Number State | CA
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