=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457762072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LATINO KIDS HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2014
-----------------------------------------------------
Last Update Date | 05/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 W WHITTIER BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-4737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-728-8588
-----------------------------------------------------
Fax | 323-728-4444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 W WHITTIER BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-4737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-728-8588
-----------------------------------------------------
Fax | 323-728-4444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. ETELVINA DE LA TORRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-728-8588
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------