Healthcare Provider Details

I. General information

NPI: 1861106908
Provider Name (Legal Business Name): FC COMPREHENSIVE HEALTHCARE A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 W ALONDRA BLVD
COMPTON CA
90220-3533
US

IV. Provider business mailing address

4525 EAGLE ROCK BLVD
LOS ANGELES CA
90041-3214
US

V. Phone/Fax

Practice location:
  • Phone: 310-933-8755
  • Fax: 310-933-8738
Mailing address:
  • Phone: 818-846-4469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TEODULO BONZON
Title or Position: CFO
Credential: LCSW
Phone: 818-846-4469