Healthcare Provider Details

I. General information

NPI: 1285751024
Provider Name (Legal Business Name): SAN JOSE COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11950 INGLEWOOD AVE
HAWTHORNE CA
90250
US

IV. Provider business mailing address

PO BOX 903
PALOS VERDES ESTATES CA
90274-0903
US

V. Phone/Fax

Practice location:
  • Phone: 310-349-8338
  • Fax: 310-349-8340
Mailing address:
  • Phone: 310-349-8338
  • Fax: 310-349-8340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberA055334
License Number StateCA

VIII. Authorized Official

Name: REZA DANESH
Title or Position: CEO
Credential: MD
Phone: 310-349-8338