=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114963642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URDC HUMAN SERVICES CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1460 N LAKE AVE
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91104-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-398-3796
-----------------------------------------------------
Fax | 626-398-3895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1460 N LAKE AVE P.O. BOX 41274
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91104-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-398-3796
-----------------------------------------------------
Fax | 626-398-3895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. AL SORKIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 626-398-3796
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | CMM70645F
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------