=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780238675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IGCN HEALTHCARE PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2019
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6153 COLGATE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-433-4165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6153 COLGATE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-433-4165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/CLINICAL DIRECTOR
-----------------------------------------------------
Name | CAMERON NESBITT
-----------------------------------------------------
Credential | M.S., BCBA
-----------------------------------------------------
Telephone | 323-433-4165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------