Healthcare Provider Details

I. General information

NPI: 1841500253
Provider Name (Legal Business Name): EASTSIDE DIABETES CARE MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5836 E BEVERLY BLVD
LOS ANGELES CA
90022-2824
US

IV. Provider business mailing address

5836 E BEVERLY BLVD
LOS ANGELES CA
90022-2824
US

V. Phone/Fax

Practice location:
  • Phone: 323-726-0370
  • Fax: 323-726-0239
Mailing address:
  • Phone: 323-726-0370
  • Fax: 323-726-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA33652
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberA33652
License Number StateCA

VIII. Authorized Official

Name: MRS. ALTAGRACIA A RODRIGUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 323-726-0370