Healthcare Provider Details

I. General information

NPI: 1609533587
Provider Name (Legal Business Name): LOURDES G BAHAMONDE DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7643 ATLANTIC AVE
CUDAHY CA
90201-5019
US

IV. Provider business mailing address

147 N MAYFLOWER AVE
MONROVIA CA
91016-2005
US

V. Phone/Fax

Practice location:
  • Phone: 213-373-1265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LOURDES G BAHAMONDE
Title or Position: CEO
Credential: D.O.
Phone: 516-526-9192