# 12310 LOWER AZUSA RD,

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174813299
- **Authorized official:** MR. KYLE FORTSON (TCM COORDINATOR)
- **Authorized official phone:** (626) 579-8593

## Contact information

- **Practice address:** 12310 LOWER AZUSA AVE, ARCADIA, CA 91006
- **Practice address phone:** (626) 579-8593
- **Practice address fax:** (562) 433-1029
- **Mailing address:** 12310 LOWER AZUSA RD, ARCADIA, CA 91006-5872
- **Mailing address phone:** (626) 579-8593
- **Mailing address fax:** (562) 433-1029

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251B00000X | Case Management Agency | — | NULL | Yes |

## Other

- **Enumeration date:** 04/11/2011
- **Last updated:** 04/11/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 171M00000X | CASE MANAGER/CARE COORDINATOR | CA |