Healthcare Provider Details

I. General information

NPI: 1396378030
Provider Name (Legal Business Name): LONG BEACH VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W 190TH ST STE 100
GARDENA CA
90248-4321
US

IV. Provider business mailing address

PO BOX 94407
CLEVELAND OH
44101-4407
US

V. Phone/Fax

Practice location:
  • Phone: 702-341-3152
  • Fax: 702-341-3503
Mailing address:
  • Phone: 702-341-3152
  • Fax: 702-341-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN DENISE POTTER
Title or Position: NPI TEAM LEAD
Credential:
Phone: 202-382-2579