Provider Demographics
NPI:1235284811
Name:LOS ANGELES COUNTY - LA PUENTE MTU
Entity Type:Organization
Organization Name:LOS ANGELES COUNTY - LA PUENTE MTU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING DIRECTOR, CMS
Authorized Official - Prefix:
Authorized Official - First Name:SHAVONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBBER-CHRISTMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-569-6001
Mailing Address - Street 1:9320 TELSTAR AVE STE 226
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 TONOPAH AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2460
Practice Address - Country:US
Practice Address - Phone:626-933-3234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00013FMedicaid