Provider Demographics
NPI:1609453539
Name:RE. AWAKENED FAITH COMMUNITY SERVICES LLC
Entity Type:Organization
Organization Name:RE. AWAKENED FAITH COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:323-239-4880
Mailing Address - Street 1:P.O. BOX 5023
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90224-5023
Mailing Address - Country:US
Mailing Address - Phone:800-936-0012
Mailing Address - Fax:
Practice Address - Street 1:1516 E. 125TH ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-1004
Practice Address - Country:US
Practice Address - Phone:800-936-0012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health