Provider Demographics
NPI:1902024276
Name:INTERCONNECTION CENTER INC.
Entity Type:Organization
Organization Name:INTERCONNECTION CENTER INC.
Other - Org Name:GRAND AVENUE CENTER FOR DIGNITY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-747-4626
Mailing Address - Street 1:3833 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-1311
Mailing Address - Country:US
Mailing Address - Phone:213-747-4626
Mailing Address - Fax:
Practice Address - Street 1:3833 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-1311
Practice Address - Country:US
Practice Address - Phone:213-747-4626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190383AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6893OtherSUBSTANCE ABUSE REHAB