Provider Demographics
NPI:1275669871
Name:IMMACULATE CARE CENTER INC
Entity Type:Organization
Organization Name:IMMACULATE CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GODDAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:IMAKAVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-383-1124
Mailing Address - Street 1:3540 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 818
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2307
Mailing Address - Country:US
Mailing Address - Phone:213-383-1124
Mailing Address - Fax:213-383-0261
Practice Address - Street 1:3540 WILSHIRE BLVD
Practice Address - Street 2:SUITE 818
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2307
Practice Address - Country:US
Practice Address - Phone:213-383-1124
Practice Address - Fax:213-383-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190479AN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190479ANOtherADP
CA02113308Medicare UPIN