Provider Demographics
NPI:1205564549
Name:CRENSHAW ENTREPRENEURIAL ACADEMY
Entity type:Organization
Organization Name:CRENSHAW ENTREPRENEURIAL ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-450-7412
Mailing Address - Street 1:206 W 1ST ST UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2806
Mailing Address - Country:US
Mailing Address - Phone:424-450-7412
Mailing Address - Fax:
Practice Address - Street 1:5125 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1853
Practice Address - Country:US
Practice Address - Phone:424-450-7412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities