Provider Demographics
NPI:1871852996
Name:TOTAL FAMILY SUPPORT CLINIC
Entity Type:Organization
Organization Name:TOTAL FAMILY SUPPORT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HR
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VERKHOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:213-213-0581
Mailing Address - Street 1:830 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-3006
Mailing Address - Country:US
Mailing Address - Phone:213-213-0581
Mailing Address - Fax:213-213-0580
Practice Address - Street 1:11133 OMELVENY AVE
Practice Address - Street 2:ROOM #506
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4426
Practice Address - Country:US
Practice Address - Phone:213-213-0581
Practice Address - Fax:213-213-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA196834Medicaid