Organization
12310 LOWER AZUSA RD,
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KYLE FORTSON (TCM COORDINATOR)
(626) 579-8593
Entity
Organization
Contact information
Practice address
12310 LOWER AZUSA AVE, ARCADIA, CA 91006
(626) 579-8593
(562) 433-1029
Mailing address
12310 LOWER AZUSA RD, ARCADIA, CA 91006-5872
(626) 579-8593
(562) 433-1029
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
171M00000X
CASE MANAGER/CARE COORDINATOR
CA
Enumeration date
04/11/2011
Last updated
04/11/2011
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