Healthcare Provider Details

I. General information

NPI: 1285841635
Provider Name (Legal Business Name): MED SITE HACIENDA HEIGHTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15060 E. IMPERIAL HWY
LA MIRADA CA
90638
US

IV. Provider business mailing address

15060 E. IMPERIAL HWY
LA MIRADA CA
90638
US

V. Phone/Fax

Practice location:
  • Phone: 562-902-5305
  • Fax: 562-902-0835
Mailing address:
  • Phone: 562-902-5305
  • Fax: 562-902-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: PAT BRAY
Title or Position: VICE PRESIDENT
Credential: RN
Phone: 562-902-7757