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NPI Code Detail

MEDICARE: SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM

MEDICARE: SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM
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
1251S00000XCommunity/Behavioral Health Agency

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17654OTHERCAPROVIDER NUMBER

General Provider Information

NPI Number : 1689793739
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM
Provider Business Mailing Address
First Line : 2610 INDUSTRY WAY
Second Line : SUITE A
City : LYNWOOD
State : CA
Zip : 90262-4028
Country : US
Telephone Number : 310-631-8004
Fax Number : 310-631-7830
Provider Business Practice Location Address
First Line : 2594 INDUSTRY WAY
Second Line :
City : LYNWOOD
State : CA
Zip : 90262-4015
Country : US
Telephone Number : 310-667-4070
Fax Number : 310-667-4072
Authorized Official
Title or Position : CEO/PRESIDENT
Name : JACK M BARBOUR
Credential : MD
Telephone Number : 310-631-8004
Provider Enumeration Date : 03/28/2007
Last Update Date : 05/09/2018

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2594 INDUSTRY WAY
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90262-4015
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1487847083 — YADIRA DELSOCORRO SOTO
Practice Location Address:
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LYNWOOD, CA
90262-4015
Practice Phone: 310-667-4070
Practice Fax:
1700065786 — SOLEDAD RAMIREZ
Practice Location Address:
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LYNWOOD, CA
90262-4015
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Practice Fax:
1427364199 — JESSICA TAVERA
Practice Location Address:
2594 INDUSTRY WAY
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90262-4015
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Directions to “SOUTHERN CALIFORNIA HEALTH & REHABILITATION PROGRAM ” Practice Location

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