Healthcare Provider Details

I. General information

NPI: 1972251577
Provider Name (Legal Business Name): LOS ANGELES COMMUNITY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2022
Last Update Date: 03/13/2022
Certification Date: 03/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 W OLYMPIC BLVD SUITE 124
LOS ANGELES CA
90006-3734
US

IV. Provider business mailing address

1830 W OLYMPIC BLVD SUITE 124
LOS ANGELES CA
90006-3734
US

V. Phone/Fax

Practice location:
  • Phone: 323-852-3245
  • Fax: 213-325-6618
Mailing address:
  • Phone: 323-852-3245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. BRANDON SAEJOON OH
Title or Position: CEO/PRESIDENT
Credential:
Phone: 213-249-0001