Provider Demographics
NPI:1316445414
Name:INSTITUTE ON AGING - SOUTHERN CALIFORNIA LLC
Entity type:Organization
Organization Name:INSTITUTE ON AGING - SOUTHERN CALIFORNIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL AND ADMIN OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLADES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-750-4101
Mailing Address - Street 1:3575 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3212
Mailing Address - Country:US
Mailing Address - Phone:415-750-4111
Mailing Address - Fax:
Practice Address - Street 1:3200 E GUASTI RD STE 173
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8660
Practice Address - Country:US
Practice Address - Phone:415-823-6215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316445414Medicaid
CA1942418884Medicaid
CA1285906164Medicaid
CA1629251772Medicaid
CA1497964647Medicaid
CA1114132941Medicaid