Healthcare Provider Details

I. General information

NPI: 1386285997
Provider Name (Legal Business Name): HUNTINGTON PARK CLINICA MEDICA GENERAL, MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 W 7TH ST
LOS ANGELES CA
90057-4002
US

IV. Provider business mailing address

PO BOX 1682
BEVERLY HILLS CA
90213-1682
US

V. Phone/Fax

Practice location:
  • Phone: 213-384-3434
  • Fax: 213-386-2039
Mailing address:
  • Phone: 213-739-3282
  • Fax: 213-384-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSE LUIS CARRILLO JR.
Title or Position: OFFICE MANAGER
Credential:
Phone: 213-739-3282