Provider Demographics
NPI:1871552653
Name:THE ELIZABETH CENTER FOR CANCER DETECTION
Entity type:Organization
Organization Name:THE ELIZABETH CENTER FOR CANCER DETECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-977-8920
Mailing Address - Street 1:1127 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4001
Mailing Address - Country:US
Mailing Address - Phone:213-481-2511
Mailing Address - Fax:213-481-1913
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4001
Practice Address - Country:US
Practice Address - Phone:213-481-2511
Practice Address - Fax:213-481-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000031261QC1500X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70685FMedicaid
CAZZZ53363ZOtherBLUE SHIELD OF CALIF
CACMM70685FMedicaid