Provider Demographics
NPI:1407378458
Name:KCCC-AMITY
Entity Type:Organization
Organization Name:KCCC-AMITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-432-5093
Mailing Address - Street 1:4211 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5622
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:
Practice Address - Street 1:3745 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-4332
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEDREN COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)