1114543113 NPI number — SERRA COMMUNITY MEDICAL CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114543113 NPI number — SERRA COMMUNITY MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERRA COMMUNITY MEDICAL 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:
SERRA COMMUNITY MEDICAL CLINIC- SUNLAND
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:
1114543113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9375 SAN FERNANDO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91352-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-504-4700
Provider Business Mailing Address Fax Number:
818-504-4690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8426 SUNLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91352-3436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-504-4526
Provider Business Practice Location Address Fax Number:
818-504-4690
Provider Enumeration Date:
06/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
LILY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
818-504-4701

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1275545725 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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