=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275878753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEINGART CENTER ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2012
-----------------------------------------------------
Last Update Date | 12/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 566 S SAN PEDRO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90013-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-689-2117
-----------------------------------------------------
Fax | 213-623-0408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 566 S SAN PEDRO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90013-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-689-2117
-----------------------------------------------------
Fax | 213-623-0408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT -PROGS & SVRS
-----------------------------------------------------
Name | TROY VAUGHN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-689-2117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 190541AN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------