Provider Demographics
NPI:1124467279
Name:REHOBOTH COURAGE CENTER
Entity type:Organization
Organization Name:REHOBOTH COURAGE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ADEFEMI
Authorized Official - Middle Name:OLUFISAYO
Authorized Official - Last Name:ADEGBESAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-663-0789
Mailing Address - Street 1:716 W COMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-3015
Mailing Address - Country:US
Mailing Address - Phone:310-663-0789
Mailing Address - Fax:
Practice Address - Street 1:718 W COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-3015
Practice Address - Country:US
Practice Address - Phone:310-663-0789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REHOBOTH COURAGE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-21
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629201629Medicaid