Healthcare Provider Details

I. General information

NPI: 1639234354
Provider Name (Legal Business Name): ALLERGY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

11620 WILSHIRE BLVD SUITE 200
LOS ANGELES CA
90025-1706
US

IV. Provider business mailing address

11620 WILSHIRE BLVD SUITE 200
LOS ANGELES CA
90025-1706
US

V. Phone/Fax

Practice location:
  • Phone: 310-312-5050
  • Fax: 310-575-9292
Mailing address:
  • Phone: 310-312-5050
  • Fax: 310-575-9292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: JOY VERNON
Title or Position: BILLER
Credential:
Phone: 310-478-0964