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General NPI Number Information
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NPI Number | 1457529760
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Entity Type | Organization
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Legal Business Name | AMERICAN SUPPORT GROUP
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Dates
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Enumeration Date | 02/20/2008
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Last Update Date | 02/20/2008
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Provider Practice Location Address
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Address Line | 15222 ERIEL AVE
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City | GARDENA
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State | CA
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Zip | 90249-4019
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Country | US
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Telephone | 310-644-1288
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Fax | 310-856-4705
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Provider Business Mailing Address
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Address Line | 15222 ARIEL AVE
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City | GARDENA
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State | CA
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Zip | 90249
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Country | US
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Telephone | 310-644-1288
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Fax | 310-856-4705
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MRS. ADELINE EKWEBELEM MADAUBUCHI
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Credential |
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Telephone | 310-644-1288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 190587AN
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License Number State | CA
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