MEDICARE: THE COMPASSIONATE SAMARITAN, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	360911118	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	360911118	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1407089295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE COMPASSIONATE SAMARITAN, INC

Provider Business Mailing Address
First Line	:	3662 ARDILLA AVE
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-5635
Country	:	US
Telephone Number	:	626-939-4433
Fax Number	:	626-698-4801

Provider Business Practice Location Address
First Line	:	3662 ARDILLA AVE
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-5635
Country	:	US
Telephone Number	:	626-939-4433
Fax Number	:	626-698-4801

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. THOMAS ALLEN HOWARD
Credential	:
Telephone Number	:	626-939-4433

Provider Enumeration Date	:	08/27/2009
Last Update Date	:	08/27/2009

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