Provider Demographics
NPI:1154583979
Name:DEPARTMENT OF VETERAN AFFAIRS
Entity type:Organization
Organization Name:DEPARTMENT OF VETERAN AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECREATION THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERMAINE
Authorized Official - Middle Name:LOVE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-478-3711
Mailing Address - Street 1:12635 S HALO DR
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1828
Mailing Address - Country:US
Mailing Address - Phone:310-608-1781
Mailing Address - Fax:
Practice Address - Street 1:12635 S HALO DR
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-1828
Practice Address - Country:US
Practice Address - Phone:310-608-1781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital