Provider Demographics
NPI:1477255222
Name:LOS ANGELES RENAISSANCE PROJECT
Entity Type:Organization
Organization Name:LOS ANGELES RENAISSANCE PROJECT
Other - Org Name:L.A.R.P
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:MARCHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-578-9290
Mailing Address - Street 1:1216 W MADDOX ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-2241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1216 W MADDOX ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-2241
Practice Address - Country:US
Practice Address - Phone:562-578-9290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty