Healthcare Provider Details

I. General information

NPI: 1386927374
Provider Name (Legal Business Name): CLINICA MEDICA SAN PEDRO OF CALIFORNIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 GARVEY AVE STE 5B
EL MONTE CA
91732-4534
US

IV. Provider business mailing address

11725 GARVEY AVE STE 5B
EL MONTE CA
91732-4534
US

V. Phone/Fax

Practice location:
  • Phone: 626-579-0999
  • Fax: 626-579-2999
Mailing address:
  • Phone: 626-579-0999
  • Fax: 626-579-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSE MANUEL DIAZ
Title or Position: PRESIDENT AND OWNER
Credential: MD
Phone: 626-579-0999