Healthcare Provider Details

I. General information

NPI: 1760585129
Provider Name (Legal Business Name): COLIMA MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 S AZUSA AVE SUITE 205
HACIENDA HEIGHTS CA
91745
US

IV. Provider business mailing address

1850 S AZUSA AVE SUITE 205
HACIENDA HEIGHTS CA
91745
US

V. Phone/Fax

Practice location:
  • Phone: 626-964-2880
  • Fax: 626-964-2834
Mailing address:
  • Phone: 626-964-2880
  • Fax: 626-964-2834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA67423
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA37924
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA37925
License Number StateCA

VIII. Authorized Official

Name: MS. LIJI LIU
Title or Position: SECRETARY
Credential:
Phone: 626-964-2880