Provider Demographics
NPI:1982209615
Name:DEMACHKIE, AFIF W
Entity Type:Individual
Prefix:
First Name:AFIF
Middle Name:W
Last Name:DEMACHKIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18726 S WESTERN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3858
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:1149 W 190TH ST STE 2200
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4344
Practice Address - Country:US
Practice Address - Phone:310-856-0800
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21169166106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician