Provider Demographics
NPI:1760868418
Name:NEW FAITH TRANSITIONAL LIVING
Entity Type:Organization
Organization Name:NEW FAITH TRANSITIONAL LIVING
Other - Org Name:WEST GARDENA COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-436-7760
Mailing Address - Street 1:2233 W ROSECRANS AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2905
Mailing Address - Country:US
Mailing Address - Phone:310-436-7760
Mailing Address - Fax:
Practice Address - Street 1:2233 W ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2905
Practice Address - Country:US
Practice Address - Phone:310-436-7760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20AA5193207Q00000X
CAPA12545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty