Healthcare Provider Details

I. General information

NPI: 1720440258
Provider Name (Legal Business Name): BC MEDICAL, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2438 MANHATTAN AVE
HERMOSA BEACH CA
90254-2541
US

IV. Provider business mailing address

2438 MANHATTAN AVE
HERMOSA BEACH CA
90254-2541
US

V. Phone/Fax

Practice location:
  • Phone: 323-333-0831
  • Fax: 310-306-5555
Mailing address:
  • Phone: 323-333-0831
  • Fax: 310-306-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A13050
License Number StateCA

VIII. Authorized Official

Name: KATHRYN SHANNON MCMENAMAN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 323-333-0831