Healthcare Provider Details

I. General information

NPI: 1336355320
Provider Name (Legal Business Name): PARKLANE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 NORTH LONG BEACH BL.
COMPTON CA
90221
US

IV. Provider business mailing address

508 NORTH LONG BEACH BL.
COMPTON CA
90221
US

V. Phone/Fax

Practice location:
  • Phone: 310-637-3989
  • Fax: 310-637-9325
Mailing address:
  • Phone: 310-637-3989
  • Fax: 310-637-9325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: GEORGE C IFEORAH
Title or Position: DIRECTOR
Credential: LAC
Phone: 310-637-3989