Provider Demographics
NPI:1760665582
Name:KIMBO DRUG & ALCOHOL REHABILITATION SERVICES
Entity Type:Organization
Organization Name:KIMBO DRUG & ALCOHOL REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KESTER
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:OUDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSE PSYCH TECH
Authorized Official - Phone:310-549-5532
Mailing Address - Street 1:407 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-5803
Mailing Address - Country:US
Mailing Address - Phone:310-549-5532
Mailing Address - Fax:
Practice Address - Street 1:407 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5803
Practice Address - Country:US
Practice Address - Phone:310-549-5532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty