MEDICARE: COMMUNITY RESIDENTIAL CARE 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
1	282N00000X	General Acute Care Hospital	483652	CA

General Provider Information

NPI Number	:	1871691352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY RESIDENTIAL CARE PROGRAM

Provider Business Mailing Address
First Line	:	1416 W 103RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-4510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1416 W 103RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-4510
Country	:	US
Telephone Number	:	323-777-0269
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED NURSE
Name	:	MS. DENISE MARIE POLK
Credential	:
Telephone Number	:	310-478-3711

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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