Provider Demographics
NPI:1174813299
Name:12310 LOWER AZUSA RD,
Entity type:Organization
Organization Name:12310 LOWER AZUSA RD,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TCM COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-579-8593
Mailing Address - Street 1:12310 LOWER AZUSA RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5872
Mailing Address - Country:US
Mailing Address - Phone:626-579-8593
Mailing Address - Fax:562-433-1029
Practice Address - Street 1:12310 LOWER AZUSA AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006
Practice Address - Country:US
Practice Address - Phone:626-579-8593
Practice Address - Fax:562-433-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XOtherCASE MANAGER/CARE COORDINATOR