Healthcare Provider Details

I. General information

NPI: 1790864213
Provider Name (Legal Business Name): EAST LOS ANGELES CARDIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E CESAR E CHAVEZ AVE SUITE 125
LOS ANGELES CA
90033-2464
US

IV. Provider business mailing address

1701 E CESAR E CHAVEZ AVE SUITE 125
LOS ANGELES CA
90033-2464
US

V. Phone/Fax

Practice location:
  • Phone: 323-441-1122
  • Fax: 323-441-1172
Mailing address:
  • Phone: 323-441-1122
  • Fax: 323-441-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: RAINIER A MANZANILLA
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 323-441-1122