Healthcare Provider Details

I. General information

NPI: 1639878143
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 S CENTRAL AVE
GLENDALE CA
91204-2504
US

IV. Provider business mailing address

8527 SEPULVEDA BLVD
NORTH HILLS CA
91343-5824
US

V. Phone/Fax

Practice location:
  • Phone: 818-895-3100
  • Fax: 818-830-0811
Mailing address:
  • Phone: 818-895-3100
  • Fax: 818-830-0811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. NIK GUPTA
Title or Position: CEO & PRESIDENT
Credential:
Phone: 818-895-3100