1710102009 NPI number — MISSION CITY COMMUNITY NETWORK, INC.

Table of content: (NPI 1710102009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710102009 NPI number — MISSION CITY COMMUNITY NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION CITY COMMUNITY NETWORK, 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:
1710102009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15206 PARTHENIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91343-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-895-3100
Provider Business Mailing Address Fax Number:
818-892-3352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4842 HOLLYWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90027-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-644-1110
Provider Business Practice Location Address Fax Number:
323-644-1171
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
NIK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
818-895-3100

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  960001162 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: 960001162 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 960001162 , 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: FHC70938F . This is a "MEDICAL PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HAP70436F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 551067 . This is a "MEDICARE FQHC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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