Provider Demographics
NPI:1275843369
Name:ACADEMIA MODERNA
Entity Type:Organization
Organization Name:ACADEMIA MODERNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SCHOOL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:XAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-251-7123
Mailing Address - Street 1:2410 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WALNUT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6342
Mailing Address - Country:US
Mailing Address - Phone:323-251-7123
Mailing Address - Fax:323-588-5354
Practice Address - Street 1:2410 BROADWAY
Practice Address - Street 2:
Practice Address - City:WALNUT PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-6342
Practice Address - Country:US
Practice Address - Phone:323-251-7123
Practice Address - Fax:323-588-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0120097251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0120097OtherLEA
CA19 64733 0120097OtherCDS CODE