MEDICARE: SAN CRISTOBAL MEDICAL GROUP

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	261Q00000X	Clinic/Center		CA

General Provider Information

NPI Number	:	1972553493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN CRISTOBAL MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1930 WILSHIRE BLVD
Second Line	:	SUITE 405
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-3605
Country	:	US
Telephone Number	:	213-413-4203
Fax Number	:	213-413-5615

Provider Business Practice Location Address
First Line	:	1061 E VERNON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-3772
Country	:	US
Telephone Number	:	213-413-4203
Fax Number	:	213-413-5615

Authorized Official
Title or Position	:	CEO
Name	:	MR. ANIBAL FALLA
Credential	:
Telephone Number	:	213-413-4203

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	07/21/2022

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