Healthcare Provider Details

I. General information

NPI: 1073832887
Provider Name (Legal Business Name): INGLEWOOD FAMILY MEDICAL CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 W IMPERIAL HWY
INGLEWOOD CA
90303-2810
US

IV. Provider business mailing address

3215 W IMPERIAL HWY
INGLEWOOD CA
90303-2810
US

V. Phone/Fax

Practice location:
  • Phone: 310-677-3595
  • Fax: 310-355-8373
Mailing address:
  • Phone: 310-677-3595
  • Fax: 310-355-8373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA61290
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14869
License Number StateCA

VIII. Authorized Official

Name: MRS. ROBIN DEANNA RILEY-GARNER
Title or Position: SEC/TRES
Credential: PA
Phone: 310-677-3595