Healthcare Provider Details

I. General information

NPI: 1699975557
Provider Name (Legal Business Name): SAN ANGEL MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2661 E FLORENCE AVE SUUITE D-1
HUNTINGTON PARK CA
90255-4793
US

IV. Provider business mailing address

2661 E FLORENCE AVE SUUITE D-1
HUNTINGTON PARK CA
90255-4793
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-6113
  • Fax:
Mailing address:
  • Phone: 323-588-6113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15560
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA44599
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG86496
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA52088
License Number StateCA

VIII. Authorized Official

Name: STEPHINE KRAMER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 323-588-6113