MEDICARE: ASSISTANCE LEAGUE OF SAN PEDRO-SOUTH BAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1124442850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASSISTANCE LEAGUE OF SAN PEDRO-SOUTH BAY

Provider Business Mailing Address
First Line	:	1441 W 8TH ST
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90732-3803
Country	:	US
Telephone Number	:	310-832-8355
Fax Number	:	310-832-8460

Provider Business Practice Location Address
First Line	:	1441 W 8TH ST
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90732-3803
Country	:	US
Telephone Number	:	310-832-8355
Fax Number	:	310-832-8460

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. SHARON JEAN COLE
Credential	:
Telephone Number	:	310-435-2624

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	12/03/2019

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