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General NPI Number Information
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NPI Number | 1568679959
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Entity Type | Organization
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Legal Business Name | MARY'S HOUSE
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 07/03/2008
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Provider Practice Location Address
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Address Line | 14901 CONDON AVE
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City | LAWNDALE
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State | CA
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Zip | 90260-1216
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Country | US
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Telephone | 310-739-3585
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Fax | 310-675-4551
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Provider Business Mailing Address
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Address Line | 14901 CONDON AVE
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City | LAWNDALE
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State | CA
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Zip | 90260-1216
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Country | US
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Telephone | 310-739-3585
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Fax | 310-675-4551
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Authorized Official
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Title or Position | LICENSEE
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Name | DR. EUGENE HARDIN
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Credential | M.D.
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Telephone | 310-739-3585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 960000992
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License Number State | CA
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