Healthcare Provider Details

I. General information

NPI: 1639334303
Provider Name (Legal Business Name): THE CHILDREN'S CLINIC, SERVING CHILDREN AND THEIR FAMILIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E COLUMBIA ST STE 201&6
LONG BEACH CA
90806-1620
US

IV. Provider business mailing address

455 E COLUMBIA ST STE 201&6
LONG BEACH CA
90806-1620
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-0400
  • Fax:
Mailing address:
  • Phone: 562-933-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number960000104
License Number StateCA

VIII. Authorized Official

Name: DR. ELISA NICHOLAS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D
Phone: 562-933-0432