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General NPI Number Information
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NPI Number | 1699580068
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Entity Type | Organization
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Legal Business Name | KEDREN COMMUNITY CARE CLINIC - MOBILE UNIT
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Dates
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Enumeration Date | 02/11/2025
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Last Update Date | 02/11/2025
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Provider Practice Location Address
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Address Line | 4211 AVALON BLVD BLDG A
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City | LOS ANGELES
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State | CA
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Zip | 90011-5622
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Country | US
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Telephone | 323-234-0616
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Fax | 323-515-7006
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Provider Business Mailing Address
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Address Line | 4211 AVALON BLVD BLDG A
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City | LOS ANGELES
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State | CA
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Zip | 90011-5622
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Country | US
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Telephone | 323-234-0616
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Fax | 323-515-7006
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Authorized Official
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Title or Position | CHIEF INFORMATION OFFICER
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Name | MR. JASON ALEXANDER WARNER
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Credential | MHA, MBA
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Telephone | 323-515-7010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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