Provider Demographics
NPI:1700256963
Name:MABO, JOHN (RAS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MABO
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W MANCHESTER AVE
Mailing Address - Street 2:5
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-5770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W MANCHESTER AVE
Practice Address - Street 2:5
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-5770
Practice Address - Country:US
Practice Address - Phone:323-750-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-M1209141145101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)