Provider Demographics
NPI:1831816693
Name:OLMOS, ISRAEL JR (NONE)
Entity type:Individual
Prefix:
First Name:ISRAEL
Middle Name:
Last Name:OLMOS
Suffix:JR
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8238 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1937
Mailing Address - Country:US
Mailing Address - Phone:213-425-5791
Mailing Address - Fax:
Practice Address - Street 1:100 N PACIFIC COAST HWY STE 1400
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5602
Practice Address - Country:US
Practice Address - Phone:424-282-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician