Healthcare Provider Details

I. General information

NPI: 1821375965
Provider Name (Legal Business Name): SOUTHBAY FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23517 MAIN ST SUITE # 103
CARSON CA
90745-5251
US

IV. Provider business mailing address

23517 S MAIN ST. SUITE # 103
CARSON CA
90745
US

V. Phone/Fax

Practice location:
  • Phone: 310-834-5388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number19910
License Number StateCA

VIII. Authorized Official

Name: DR. SHRIKANT TAMHANE
Title or Position: DIRECTOR
Credential: M.D.
Phone: 310-834-5388