Provider Demographics
NPI:1386868685
Name:LOS ANGELES WINGS OF FAITH
Entity type:Organization
Organization Name:LOS ANGELES WINGS OF FAITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-833-2719
Mailing Address - Street 1:9626 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-4311
Mailing Address - Country:US
Mailing Address - Phone:323-833-9719
Mailing Address - Fax:323-779-6495
Practice Address - Street 1:9626 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-4311
Practice Address - Country:US
Practice Address - Phone:323-833-9719
Practice Address - Fax:323-779-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health