Healthcare Provider Details

I. General information

NPI: 1588078166
Provider Name (Legal Business Name): EDGEMONT MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 SANTA MONICA BLVD
LOS ANGELES CA
90029-2634
US

IV. Provider business mailing address

4864 SANTA MONICA BLVD
LOS ANGELES CA
90029-2634
US

V. Phone/Fax

Practice location:
  • Phone: 818-504-7265
  • Fax: 818-504-1623
Mailing address:
  • Phone: 818-504-7265
  • Fax: 818-504-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A10630
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A10630
License Number StateCA

VIII. Authorized Official

Name: ANTONIO ZAMORANO
Title or Position: PRESIDENT
Credential: D.O.
Phone: 818-504-7265