MEDICARE: MISSION CITY COMMUNITY NETWORK, INC.

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	261QC1500X	Community Health Clinic/Center	960001162	CA
2	261QF0400X	Federally Qualified Health Center (FQHC)	960001162	CA
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	960001162	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	551067	OTHER	CA	MEDICARE FQHC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	FHC70938F	OTHER	CA	MEDICAL PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710102009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION CITY COMMUNITY NETWORK, INC.

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

Provider Business Practice Location Address
First Line	:	4842 HOLLYWOOD BLVD
Second Line	:
City	:	HOLLYWOOD
State	:	CA
Zip	:	90027-5302
Country	:	US
Telephone Number	:	323-644-1110
Fax Number	:	323-644-1171

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. NIK GUPTA
Credential	:
Telephone Number	:	818-895-3100

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	03/21/2011

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Directions to “MISSION CITY COMMUNITY NETWORK, INC. ” Practice Location

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