Provider Demographics
NPI:1942415690
Name:ADVANCED HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:ADVANCED HEALTH CENTERS, INC.
Other - Org Name:SAN PEDRO ADHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALENTINA
Authorized Official - Middle Name:V
Authorized Official - Last Name:LEIBZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-519-9880
Mailing Address - Street 1:430 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2632
Mailing Address - Country:US
Mailing Address - Phone:310-519-9880
Mailing Address - Fax:310-519-8072
Practice Address - Street 1:430 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2632
Practice Address - Country:US
Practice Address - Phone:310-519-9880
Practice Address - Fax:310-519-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70368FMedicaid