MEDICARE: TESTIMONIAL COMMUNITY LOVE CENTER

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1578152179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TESTIMONIAL COMMUNITY LOVE CENTER

Provider Business Mailing Address
First Line	:	5721 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90062-2714
Country	:	US
Telephone Number	:	323-291-6753
Fax Number	:

Provider Business Practice Location Address
First Line	:	5721 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90062-2714
Country	:	US
Telephone Number	:	323-291-6753
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	MS. ZONEKE DOMINO
Credential	:
Telephone Number	:	504-495-2551

Provider Enumeration Date	:	01/18/2021
Last Update Date	:	01/18/2021

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Directions to “TESTIMONIAL COMMUNITY LOVE CENTER ” Practice Location

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