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General NPI Number Information
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NPI Number | 1275669871
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Entity Type | Organization
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Legal Business Name | IMMACULATE CARE CENTER INC
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3540 WILSHIRE BLVD SUITE 818
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City | LOS ANGELES
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State | CA
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Zip | 90010-2307
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Country | US
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Telephone | 213-383-1124
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Fax | 213-383-0261
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Provider Business Mailing Address
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Address Line | 3540 WILSHIRE BLVD SUITE 818
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City | LOS ANGELES
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State | CA
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Zip | 90010-2307
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Country | US
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Telephone | 213-383-1124
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Fax | 213-383-0261
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. GODDAY E. IMAKAVAR
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Credential |
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Telephone | 213-383-1124
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 190479AN
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License Number State | CA
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