MEDICARE: INGLEWOOD FAMILY MEDICAL CLINIC CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA14869	CA
2	207Q00000X	Family Medicine Physician	A61290	CA

General Provider Information

NPI Number	:	1073832887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INGLEWOOD FAMILY MEDICAL CLINIC CORP

Provider Business Mailing Address
First Line	:	3215 W IMPERIAL HWY
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-2810
Country	:	US
Telephone Number	:	310-677-3595
Fax Number	:	310-355-8373

Provider Business Practice Location Address
First Line	:	3215 W IMPERIAL HWY
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-2810
Country	:	US
Telephone Number	:	310-677-3595
Fax Number	:	310-355-8373

Authorized Official
Title or Position	:	SEC/TRES
Name	:	MRS. ROBIN DEANNA RILEY-GARNER
Credential	:	PA
Telephone Number	:	310-677-3595

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	05/19/2010

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Directions to “INGLEWOOD FAMILY MEDICAL CLINIC CORP ” Practice Location

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