Provider Demographics
NPI:1629416250
Name:BIENVENIDOS HEALTHY START COMMUNITY CLINIC AT WILSON HIGH SCHOOL
Entity Type:Organization
Organization Name:BIENVENIDOS HEALTHY START COMMUNITY CLINIC AT WILSON HIGH SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JACOBUS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DER COLFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-785-5923
Mailing Address - Street 1:316 W 2ND ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-3504
Mailing Address - Country:US
Mailing Address - Phone:213-785-5906
Mailing Address - Fax:213-785-5914
Practice Address - Street 1:4500 MULTNOMAH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-3703
Practice Address - Country:US
Practice Address - Phone:323-222-0970
Practice Address - Fax:323-222-0878
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIENVENIDOS CHILDREN'S CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-05
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001182261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2050805OtherCLIA
CA00343513OtherCLR