Provider Demographics
NPI:1891830964
Name:EAST LOS ANGELES REMARKABLE CITIZEN ASSN
Entity Type:Organization
Organization Name:EAST LOS ANGELES REMARKABLE CITIZEN ASSN
Other - Org Name:CASA TERRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:MSW MPA
Authorized Official - Phone:323-223-3079
Mailing Address - Street 1:3839 SELIG PLACE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031
Mailing Address - Country:US
Mailing Address - Phone:323-223-3079
Mailing Address - Fax:323-223-4684
Practice Address - Street 1:15576 LUJON ST
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745
Practice Address - Country:US
Practice Address - Phone:626-333-7554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60893FOtherMEDICAL