Healthcare Provider Details

I. General information

NPI: 1053082586
Provider Name (Legal Business Name): PIPELINE COMMUNITY SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 W REDONDO BEACH BLVD STE 212
GARDENA CA
90247-3584
US

IV. Provider business mailing address

PO BOX 80717
CITY OF INDUSTRY CA
91716-8416
US

V. Phone/Fax

Practice location:
  • Phone: 310-698-5463
  • Fax:
Mailing address:
  • Phone: 310-321-0143
  • Fax: 310-379-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VINCENT GREEN
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 310-321-0143