Healthcare Provider Details

I. General information

NPI: 1790133379
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E BUENA VISTA ST
BARSTOW CA
92311-2815
US

IV. Provider business mailing address

15206 PARTHENIA ST
NORTH HILLS CA
91343-5305
US

V. Phone/Fax

Practice location:
  • Phone: 818-895-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: NIK GUPTA
Title or Position: CEO
Credential:
Phone: 818-895-3100