Healthcare Provider Details

I. General information

NPI: 1750442836
Provider Name (Legal Business Name): ZACOALCO MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 E FLORENCE AVE
LOS ANGELES CA
90001
US

IV. Provider business mailing address

1414 E FLORENCE AVE
LOS ANGELES CA
90001
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-1383
  • Fax: 323-588-2339
Mailing address:
  • Phone: 323-588-1383
  • Fax: 323-588-2339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG75144
License Number StateCA

VIII. Authorized Official

Name: RAYMOND MENCHACA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 323-588-1383