Healthcare Provider Details

I. General information

NPI: 1659502664
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E HARDY ST SUITE 110
INGLEWOOD CA
90301-4054
US

IV. Provider business mailing address

15206 PARTHENIA ST
NORTH HILLS CA
91343-5305
US

V. Phone/Fax

Practice location:
  • Phone: 818-895-3100
  • Fax: 818-892-4651
Mailing address:
  • Phone: 818-895-3100
  • Fax: 818-892-4651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number550001476
License Number StateCA

VIII. Authorized Official

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