Provider Demographics
NPI:1679777486
Name:ST. JOHNS WELL CHILD AND FAMILY CENTER
Entity Type:Organization
Organization Name:ST. JOHNS WELL CHILD AND FAMILY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIGNER-WEEKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-749-0947
Mailing Address - Street 1:515 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3204
Mailing Address - Country:US
Mailing Address - Phone:213-749-0947
Mailing Address - Fax:213-749-7354
Practice Address - Street 1:515 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3204
Practice Address - Country:US
Practice Address - Phone:213-749-0947
Practice Address - Fax:213-749-7354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13649261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16114Medicare UPIN