Provider Demographics
NPI:1801227087
Name:CHCADA ROOSEVELT-ISHC
Entity Type:Organization
Organization Name:CHCADA ROOSEVELT-ISHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-443-5473
Mailing Address - Street 1:1419 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811
Mailing Address - Country:US
Mailing Address - Phone:916-443-5473
Mailing Address - Fax:916-443-1732
Practice Address - Street 1:456 S MATHEWS ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4326
Practice Address - Country:US
Practice Address - Phone:323-222-4591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7884OtherMEDI-CAL PROVIDER NUMBER