Provider Demographics
NPI:1790974798
Name:CRISTIAN CENTER MANOR ALCOHOL AND DRUG BEHAVIOR CENTER
Entity Type:Organization
Organization Name:CRISTIAN CENTER MANOR ALCOHOL AND DRUG BEHAVIOR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-751-3896
Mailing Address - Street 1:8721 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3321
Mailing Address - Country:US
Mailing Address - Phone:323-752-3700
Mailing Address - Fax:
Practice Address - Street 1:8721 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3321
Practice Address - Country:US
Practice Address - Phone:323-752-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109445AN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190445ANOtherSTATE CA, (AOD) ID #