Healthcare Provider Details

I. General information

NPI: 1457230260
Provider Name (Legal Business Name): MARK CARLOS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8019 COMPTON AVE
LOS ANGELES CA
90001-3409
US

IV. Provider business mailing address

8019 COMPTON AVE
LOS ANGELES CA
90001-3409
US

V. Phone/Fax

Practice location:
  • Phone: 323-586-7333
  • Fax: 323-586-7333
Mailing address:
  • Phone: 323-586-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: