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General NPI Number Information
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NPI Number | 1760868418
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Entity Type | Organization
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Legal Business Name | NEW FAITH TRANSITIONAL LIVING
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Dates
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Enumeration Date | 08/05/2015
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Last Update Date | 08/05/2015
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Provider Practice Location Address
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Address Line | 2233 W ROSECRANS AVE
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City | GARDENA
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State | CA
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Zip | 90249-2905
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Country | US
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Telephone | 310-436-7760
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Fax |
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Provider Business Mailing Address
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Address Line | 2233 W ROSECRANS AVE
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City | GARDENA
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State | CA
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Zip | 90249-2905
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Country | US
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Telephone | 310-436-7760
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALICE BLACI
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Credential |
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Telephone | 310-436-7760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA12545
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20AA5193
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License Number State | CA
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