Healthcare Provider Details

I. General information

NPI: 1710102009
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4842 HOLLYWOOD BLVD
HOLLYWOOD CA
90027-5302
US

IV. Provider business mailing address

15206 PARTHENIA ST
NORTH HILLS CA
91343-5305
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-1110
  • Fax: 323-644-1171
Mailing address:
  • Phone: 818-895-3100
  • Fax: 818-892-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number960001162
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number960001162
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number960001162
License Number StateCA

VIII. Authorized Official

Name: MR. NIK GUPTA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 818-895-3100