Healthcare Provider Details

I. General information

NPI: 1346525912
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N PRAIRIE AVE 311
INGLEWOOD CA
90301-4507
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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number960000465
License Number StateCA

VIII. Authorized Official

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