Healthcare Provider Details

I. General information

NPI: 1538095385
Provider Name (Legal Business Name): SOUTH LOS ANGELES MEDICAL GROUP PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 W FLORENCE AVE
LOS ANGELES CA
90043-5142
US

IV. Provider business mailing address

2804 W FLORENCE AVE
LOS ANGELES CA
90043-5142
US

V. Phone/Fax

Practice location:
  • Phone: 323-807-2980
  • Fax:
Mailing address:
  • Phone: 323-807-2980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNY LOPEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 562-832-6380