Provider Demographics
NPI:1770793754
Name:EAST LOS ANGELES HEALTH TASK
Entity type:Organization
Organization Name:EAST LOS ANGELES HEALTH TASK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:DELGADO
Authorized Official - Last Name:ARELLANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-261-2171
Mailing Address - Street 1:2120 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1202
Mailing Address - Country:US
Mailing Address - Phone:323-881-1112
Mailing Address - Fax:
Practice Address - Street 1:2120 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1202
Practice Address - Country:US
Practice Address - Phone:323-881-1112
Practice Address - Fax:323-261-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QC1500X, 261QC1500X, 261QF0050X, 261QF0050X, 261QP2300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Not Answered261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP00002FOtherEAPC STATE GRANT
CACMM70727FMedicaid
CA10307OtherPAMELA LEWIS FNP LIC#
CAC42346OtherCORLISS SHELTON MD LIC#
CAEAP00002FOtherEAPC STATE GRANT
CAE27241Medicare UPIN
CAWNP10307AMedicare ID - Type UnspecifiedPAMELA LEWIS FNP
CAQ15852Medicare UPIN
CAWC42346EMedicare ID - Type UnspecifiedCORLISS R. SHELTON MD