Provider Demographics
NPI:1619106838
Name:ST. JOHN'S WELL CHILD & FAMILY CENTER, INC
Entity Type:Organization
Organization Name:ST. JOHN'S WELL CHILD & FAMILY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF HUMAN RESOUCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMIK
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:323-541-1604
Mailing Address - Street 1:5701 S HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-4045
Mailing Address - Country:US
Mailing Address - Phone:323-541-1600
Mailing Address - Fax:323-541-1601
Practice Address - Street 1:5701 S HOOVER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-4045
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:323-541-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP18546261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)