Healthcare Provider Details

I. General information

NPI: 1922241215
Provider Name (Legal Business Name): SAN BERNARDINO CARDIO CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5231 ONAKNOLL AVE
LOS ANGELES CA
90043-1041
US

IV. Provider business mailing address

5231 ONAKNOLL AVE
LOS ANGELES CA
90043-1041
US

V. Phone/Fax

Practice location:
  • Phone: 323-793-9183
  • Fax:
Mailing address:
  • Phone: 323-294-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. JACQUELYN THOMPSON
Title or Position: CEO
Credential:
Phone: 323-294-8123