Provider Demographics
NPI:1770737918
Name:TOTAL FAMILY SUPPORT CLINIC
Entity type:Organization
Organization Name:TOTAL FAMILY SUPPORT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VERKHOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:213-213-0581
Mailing Address - Street 1:830 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-3006
Mailing Address - Country:US
Mailing Address - Phone:213-213-0581
Mailing Address - Fax:213-213-0580
Practice Address - Street 1:3501 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4515
Practice Address - Country:US
Practice Address - Phone:562-981-1501
Practice Address - Fax:562-981-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19-7134Medicaid