=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417147307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNITED AMERICAN INDIAN INVOLVEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 07/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 W 6TH ST STE 103
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-1896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-202-3970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3415 LINDEN AVE APT 217
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-4535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-595-9937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORK THERAPIST
-----------------------------------------------------
Name | MR. HALSEY JESSE MENENDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-202-3970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | ASW 20534
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------