Provider Demographics
NPI:1275866188
Name:PASSPORT HEALTH LOS ANGELES
Entity Type:Organization
Organization Name:PASSPORT HEALTH LOS ANGELES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RAYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-297-0700
Mailing Address - Street 1:5455 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #1802
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4201
Mailing Address - Country:US
Mailing Address - Phone:323-297-0700
Mailing Address - Fax:323-549-9423
Practice Address - Street 1:5455 WILSHIRE BLVD
Practice Address - Street 2:SUITE #1802
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4201
Practice Address - Country:US
Practice Address - Phone:323-297-0700
Practice Address - Fax:323-549-9423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center