Provider Demographics
NPI:1255548483
Name:KEDREN COMMUNITY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:KEDREN COMMUNITY HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARLE CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-432-5093
Mailing Address - Street 1:4211 SOUTH AVALON BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5622
Mailing Address - Country:US
Mailing Address - Phone:323-432-5093
Mailing Address - Fax:323-233-5015
Practice Address - Street 1:4211 SOUTH AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011
Practice Address - Country:US
Practice Address - Phone:323-432-5093
Practice Address - Fax:323-233-5015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEDREN COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-17
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO740AMedicare PIN
CAW1880Medicare PIN