Provider Demographics
NPI:1225294341
Name:SOUTHLAND OUTPATIENT RECOVERY CENTER
Entity type:Organization
Organization Name:SOUTHLAND OUTPATIENT RECOVERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SUNDAY
Authorized Official - Middle Name:I
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-884-2220
Mailing Address - Street 1:PO BOX 17144
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-7144
Mailing Address - Country:US
Mailing Address - Phone:562-884-2220
Mailing Address - Fax:
Practice Address - Street 1:920 N LONG BEACH BLVD
Practice Address - Street 2:1,2,& 3
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-2260
Practice Address - Country:US
Practice Address - Phone:562-537-3396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3027962261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)