=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558681890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENT LIVING CENTER OF KERN COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2010
-----------------------------------------------------
Last Update Date | 06/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1631 30TH STREET
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93301-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-325-1063
-----------------------------------------------------
Fax | 661-325-6702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1631 30TH STREET
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93301-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-325-1063
-----------------------------------------------------
Fax | 661-325-6702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. LOUIS E. LOPEZ
-----------------------------------------------------
Credential | B.A.
-----------------------------------------------------
Telephone | 661-325-1063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------