Provider Demographics
NPI:1104246362
Name:WATTS HEALTHCARE CORPORATION
Entity type:Organization
Organization Name:WATTS HEALTHCARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUMLAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-564-4331
Mailing Address - Street 1:10300 COMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3628
Mailing Address - Country:US
Mailing Address - Phone:323-357-6680
Mailing Address - Fax:
Practice Address - Street 1:316 E 111TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-3004
Practice Address - Country:US
Practice Address - Phone:323-568-3093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATTS HEALTHCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-25
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002583261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104246362Medicaid
CA1477649119Medicaid