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General NPI Number Information
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NPI Number | 1922131549
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Entity Type | Organization
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Legal Business Name | L. A.SOUTH HEALTH SERVIES
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1704 W MANCHESTER AVE SUITE 205
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City | LOS ANGELES
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State | CA
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Zip | 90047-3034
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Country | US
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Telephone | 323-751-0608
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Fax | 323-751-0375
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Provider Business Mailing Address
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Address Line | 1704 W MANCHESTER AVE SUITE 205
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City | LOS ANGELES
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State | CA
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Zip | 90047-3034
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Country | US
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Telephone | 323-751-0608
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Fax | 323-751-0375
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Authorized Official
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Title or Position | EXCUTUVE DIRECTOR
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Name | MR. MATTHEW E ETUK
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Credential | COUNSELOR
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Telephone | 323-751-0608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 190476AN
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License Number State | CA
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