Provider Demographics
NPI:1982822995
Name:PRIDE HEALTH SERVICES
Entity Type:Organization
Organization Name:PRIDE HEALTH SERVICES
Other - Org Name:PRIDE HEALTH SERVICES CRENSHAW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GODFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOGENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-677-9091
Mailing Address - Street 1:8619 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2330
Mailing Address - Country:US
Mailing Address - Phone:310-766-9019
Mailing Address - Fax:310-677-9401
Practice Address - Street 1:8619 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2330
Practice Address - Country:US
Practice Address - Phone:310-766-9019
Practice Address - Fax:310-677-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA701231OtherDRUG MEDI-CAL