Provider Demographics
NPI:1417378597
Name:KEDREN COMMUNITY CARE CLINIC - A
Entity type:Organization
Organization Name:KEDREN COMMUNITY CARE CLINIC - A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:MHA, MBA
Authorized Official - Phone:323-515-7010
Mailing Address - Street 1:4211 AVALON BLVD
Mailing Address - Street 2:BUILDING A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5622
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:323-432-5186
Practice Address - Street 1:4211 AVALON BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5622
Practice Address - Country:US
Practice Address - Phone:323-234-0616
Practice Address - Fax:323-515-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002516261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)