Healthcare Provider Details

I. General information

NPI: 1003469214
Provider Name (Legal Business Name): LOS ANGELES CLINICA MEDICA GENERAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 PACIFIC BLVD STE AB
HUNTINGTON PARK CA
90255-5954
US

IV. Provider business mailing address

2208 W 7TH ST
LOS ANGELES CA
90057-4002
US

V. Phone/Fax

Practice location:
  • Phone: 323-583-8383
  • Fax: 323-583-8399
Mailing address:
  • Phone: 213-384-3434
  • Fax: 213-386-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSE L CARRILLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 213-739-3282