Provider Demographics
NPI:1790050763
Name:ANIMO LOCKE TECH CHARTER HIGH SCHOOL
Entity Type:Organization
Organization Name:ANIMO LOCKE TECH CHARTER HIGH SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:323-988-3744
Mailing Address - Street 1:810 E. 111TH STREET
Mailing Address - Street 2:ROOM # 113 & 114
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001
Mailing Address - Country:US
Mailing Address - Phone:323-585-8985
Mailing Address - Fax:
Practice Address - Street 1:810 E. 111TH STREET
Practice Address - Street 2:ROOM # 113 & 114
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001
Practice Address - Country:US
Practice Address - Phone:323-585-8985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIXON RECOVERY INSTITUTE,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-09
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190622AN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7336Medicaid
CA197336Medicaid