1609251735 NPI number — T.H.E. CLINIC, INC.

Table of content: (NPI 1609251735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609251735 NPI number — T.H.E. CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T.H.E. 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:
1609251735
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3834 S WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90062-1104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-730-1920
Provider Business Mailing Address Fax Number:
213-742-6785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3721 S LA BREA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90016-5309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-730-1920
Provider Business Practice Location Address Fax Number:
213-742-6785
Provider Enumeration Date:
07/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHIEPE
Authorized Official First Name:
CLIFFORD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
INTERIM CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
323-730-1920

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  960001020 , 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: 9600001020 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com