Healthcare Provider Details

I. General information

NPI: 1942694096
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 WILLOW AVE
LA PUENTE CA
91746-1617
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: 818-893-9464
Mailing address:
  • Phone: 818-895-3100
  • Fax: 818-893-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. GLORIA LINA
Title or Position: COO
Credential:
Phone: 818-895-3100