Provider Demographics
NPI:1538106455
Name:CENTER FOR HEALTHY AGING
Entity Type:Organization
Organization Name:CENTER FOR HEALTHY AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLFAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-576-2550
Mailing Address - Street 1:2125 ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1337
Mailing Address - Country:US
Mailing Address - Phone:310-576-2550
Mailing Address - Fax:310-453-8485
Practice Address - Street 1:1527 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2354
Practice Address - Country:US
Practice Address - Phone:310-576-2550
Practice Address - Fax:310-576-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13662Medicare ID - Type Unspecified