Provider Demographics
NPI:1558753004
Name:CANON HUMAN SERVICES CENTERS, INC,
Entity Type:Organization
Organization Name:CANON HUMAN SERVICES CENTERS, INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:OLIVER
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-249-9097
Mailing Address - Street 1:9705 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3031
Mailing Address - Country:US
Mailing Address - Phone:323-249-9097
Mailing Address - Fax:323-249-9121
Practice Address - Street 1:5318-5320 S. BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3808
Practice Address - Country:US
Practice Address - Phone:323-249-9097
Practice Address - Fax:323-249-9121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190099DN251S00000X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder