Provider Demographics
NPI:1275839037
Name:SUPPLEMENTAL HEALTH CARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTH CARE
Other - Org Name:SHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-902-0768
Mailing Address - Street 1:12819 SHORT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12819 SHORT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6420
Practice Address - Country:US
Practice Address - Phone:310-902-0768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1242273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit