MEDICARE: IMMACULATE CARE CENTER INC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	190479AN	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	190479AN	OTHER	CA	ADP

General Provider Information

NPI Number	:	1275669871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMACULATE CARE CENTER INC

Provider Business Mailing Address
First Line	:	3540 WILSHIRE BLVD
Second Line	:	SUITE 818
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2307
Country	:	US
Telephone Number	:	213-383-1124
Fax Number	:	213-383-0261

Provider Business Practice Location Address
First Line	:	3540 WILSHIRE BLVD
Second Line	:	SUITE 818
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2307
Country	:	US
Telephone Number	:	213-383-1124
Fax Number	:	213-383-0261

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. GODDAY E. IMAKAVAR
Credential	:
Telephone Number	:	213-383-1124

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	08/22/2020

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Directions to “IMMACULATE CARE CENTER INC ” Practice Location

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