Healthcare Provider Details

I. General information

NPI: 1881616761
Provider Name (Legal Business Name): EAST LA PAZ MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3712 WHITTIER BLVD
LOS ANGELES CA
90023-1733
US

IV. Provider business mailing address

3712 WHITTIER BLVD
LOS ANGELES CA
90023
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-8347
  • Fax: 323-268-8368
Mailing address:
  • Phone: 323-268-8347
  • Fax: 323-268-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG56407
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA23808
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE 4677
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 15296
License Number StateCA

VIII. Authorized Official

Name: WILLIAM CHU
Title or Position: PRESIDENT
Credential: PAC
Phone: 323-268-8347