Healthcare Provider Details

I. General information

NPI: 1033529250
Provider Name (Legal Business Name): SUPERIOR CARE MEDICAL CENER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15401 S MAIN ST
GARDENA CA
90248-2214
US

IV. Provider business mailing address

15401 S MAIN ST
GARDENA CA
90248-2214
US

V. Phone/Fax

Practice location:
  • Phone: 310-225-3640
  • Fax: 310-225-3644
Mailing address:
  • Phone: 310-225-3640
  • Fax: 310-225-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberA22315
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberA22315
License Number StateCA

VIII. Authorized Official

Name: MS. PATRICIA MACIAS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 310-225-3640