Provider Demographics
NPI:1548764392
Name:ST. JOHNS COMMUNITY HEALTH
Entity Type:Organization
Organization Name:ST. JOHNS COMMUNITY HEALTH
Other - Org Name:ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE PROJECT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:SOCORRO
Authorized Official - Last Name:GENIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-541-1600
Mailing Address - Street 1:808 W 58TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3632
Mailing Address - Country:US
Mailing Address - Phone:323-541-1600
Mailing Address - Fax:323-541-1661
Practice Address - Street 1:1000 W. 50TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037
Practice Address - Country:US
Practice Address - Phone:323-541-1411
Practice Address - Fax:323-541-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861893844Medicaid