=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639367170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOS ANGELES COUNTY - SAN GABRIEL TU
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2007
-----------------------------------------------------
Last Update Date | 10/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E GRAND AVE
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-2817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-614-2260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9320 TELSTAR AVE STE 226
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91731-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-288-4584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACTING DIRECTOR, CMS
-----------------------------------------------------
Name | SHAVONDA CHRISTMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-569-6001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------