Provider Demographics
NPI:1396814893
Name:EL DORADO COMMUNITY SERVICE CENTERS
Entity Type:Organization
Organization Name:EL DORADO COMMUNITY SERVICE CENTERS
Other - Org Name:EL DORADO- VAN NUYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SEANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-254-6630
Mailing Address - Street 1:PO BOX 801809
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91380-1809
Mailing Address - Country:US
Mailing Address - Phone:661-254-6630
Mailing Address - Fax:661-254-6644
Practice Address - Street 1:6265 SEPULVEDA BLVD STE 9&10
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1114
Practice Address - Country:US
Practice Address - Phone:818-779-0555
Practice Address - Fax:818-779-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001034261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHDC70057FMedicaid
CACMM70743FMedicaid
CAHDC70057FMedicaid