Provider Demographics
NPI:1063134146
Name:DEL AIRE COMMUNITY DEVELOPMENT CENTER
Entity type:Organization
Organization Name:DEL AIRE COMMUNITY DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-612-3778
Mailing Address - Street 1:2043 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-1900
Mailing Address - Country:US
Mailing Address - Phone:310-612-3778
Mailing Address - Fax:310-676-1170
Practice Address - Street 1:2043 W 115TH ST
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-1900
Practice Address - Country:US
Practice Address - Phone:310-612-3778
Practice Address - Fax:310-676-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health