Provider Demographics
NPI:1568677235
Name:EL DORADO COMMUNITY SERVICE CENTER
Entity Type:Organization
Organization Name:EL DORADO COMMUNITY SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR V P
Authorized Official - Prefix:MR
Authorized Official - First Name:PRAMESH
Authorized Official - Middle Name:PRAKASH
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-254-6630
Mailing Address - Street 1:26460 SUMMIT CIR
Mailing Address - Street 2:SANTA CLARITA
Mailing Address - City:CALIFORNIA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-2991
Mailing Address - Country:US
Mailing Address - Phone:661-254-6630
Mailing Address - Fax:661-254-6630
Practice Address - Street 1:5200 SAN GABRIEL PL SUITE B & C
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2497
Practice Address - Country:US
Practice Address - Phone:562-222-1331
Practice Address - Fax:562-222-1322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19AP261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19-148OtherSTATE NTP LICENSE
CA19APOtherADPA