MEDICARE: KEDREN COMMUNITY CARE CLINIC - A

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	261QF0400X	Federally Qualified Health Center (FQHC)	550002516	CA

General Provider Information

NPI Number	:	1417378597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEDREN COMMUNITY CARE CLINIC - A

Provider Business Mailing Address
First Line	:	4211 AVALON BLVD
Second Line	:	HR DEPARTMENT
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-5622
Country	:	US
Telephone Number	:	323-582-2251
Fax Number	:	323-582-2251

Provider Business Practice Location Address
First Line	:	4211 AVALON BLVD STE A
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-5622
Country	:	US
Telephone Number	:	323-234-0616
Fax Number	:	323-232-2384

Authorized Official
Title or Position	:	HR CREDENTIALING COORDINATOR
Name	:	FRIDA BARRERA BEJARANO
Credential	:
Telephone Number	:	323-582-2251

Provider Enumeration Date	:	12/17/2013
Last Update Date	:	04/06/2026

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