1457470684 NPI number — ANGELES COMPREHENSIVE COMMUNITY CLINIC, INC.

Table of content: (NPI 1457470684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457470684 NPI number — ANGELES COMPREHENSIVE COMMUNITY CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELES COMPREHENSIVE COMMUNITY CLINIC, INC.
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:
Provider Other Organization Name Type Code:
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:
1457470684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3920 EAGLE ROCK BLVD.
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90065-3606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-255-5225
Provider Business Mailing Address Fax Number:
323-255-5229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3920 EAGLE ROCK BLVD.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90065-3606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-255-5225
Provider Business Practice Location Address Fax Number:
323-255-5229
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAZAROVA
Authorized Official First Name:
LIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
323-255-5225

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  550000708 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OXG182 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ552884 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1326349960 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 91355 . This is a "HEALTHY FAMILY ENROLLMENT ENTITY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CB217375 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1457470684 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G56432MM2 . This is a "LA CARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1427355981 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 8370190013 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1811043474 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: OO3991 . This is a "HEALTH NET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1427003300 . This is a "NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G56432F11 . This is a "CARE 1ST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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