Provider Demographics
NPI:1235371352
Name:WITHROW OUT A TRACE MINISTYR
Entity Type:Organization
Organization Name:WITHROW OUT A TRACE MINISTYR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTER COUNSELOR
Authorized Official - Phone:213-880-9242
Mailing Address - Street 1:4015 W 137TH ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7340
Mailing Address - Country:US
Mailing Address - Phone:310-569-5868
Mailing Address - Fax:
Practice Address - Street 1:2110 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3073
Practice Address - Country:US
Practice Address - Phone:310-569-5868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW2056302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization