Healthcare Provider Details

I. General information

NPI: 1104984137
Provider Name (Legal Business Name): BETH MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 S MAIN ST
LOS ANGELES CA
90061-1926
US

IV. Provider business mailing address

11126 S MAIN ST
LOS ANGELES CA
90061-1926
US

V. Phone/Fax

Practice location:
  • Phone: 323-779-8398
  • Fax: 323-779-8493
Mailing address:
  • Phone: 323-779-8398
  • Fax: 323-779-8493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA46478
License Number StateCA

VIII. Authorized Official

Name: EMMANUEL A AYODELE
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 323-779-8398