=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407378458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEDREN COMMUNITY CARE CLINIC - AMITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2017
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3745 S GRAND AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-233-0425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4211 AVALON BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90011-5622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-233-0425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF INFORMATION OFFICER
-----------------------------------------------------
Name | MR. JASON ALEXANDER WARNER
-----------------------------------------------------
Credential | MHA, MBA
-----------------------------------------------------
Telephone | 323-515-7010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------