=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609453539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RE. AWAKENED FAITH COMMUNITY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2021
-----------------------------------------------------
Last Update Date | 03/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1516 E. 125TH ST
-----------------------------------------------------
City | COMPTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90222-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-936-0012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 5023
-----------------------------------------------------
City | COMPTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90224-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-936-0012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. TANYA L LAWRENCE
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 323-239-4880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------