Provider Demographics
NPI:1821110115
Name:TOTAL FAMILY SUPPORT CLINIC
Entity Type:Organization
Organization Name:TOTAL FAMILY SUPPORT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-778-4227
Mailing Address - Street 1:2511 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-3111
Mailing Address - Country:US
Mailing Address - Phone:562-981-1501
Mailing Address - Fax:
Practice Address - Street 1:2511 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-3111
Practice Address - Country:US
Practice Address - Phone:562-981-1501
Practice Address - Fax:562-981-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA2395299101YA0400X, 251B00000X
CA101YA0400X101YA0400X
CA101Y0000X101YA0400X
CA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Not Answered251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID