1003011479 NPI number — LOS ANGELES MEDICAL HEALTH CLINIC

Table of content: (NPI 1003011479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003011479 NPI number — LOS ANGELES MEDICAL HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ANGELES MEDICAL HEALTH CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LOS ANGELES MEDICAL HEALTH CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003011479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 CALLE SAN RAFAEL
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00909-2693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-721-6626
Provider Business Mailing Address Fax Number:
787-725-1287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 CALLE SAN RAFAEL
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00909-2693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-721-6626
Provider Business Practice Location Address Fax Number:
787-725-1287
Provider Enumeration Date:
06/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATOS
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
IRIS
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
787-721-6626

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1820 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TC0700X , with the licence number: 0070 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207Q00000X , with the licence number: 011058 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: 9251 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RC0000X , with the licence number: 4847 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RP1001X , with the licence number: 8908 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207V00000X , with the licence number: 010561 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208100000X , with the licence number: 15909 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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