Healthcare Provider Details

I. General information

NPI: 1154457745
Provider Name (Legal Business Name): ALISO MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E 4TH ST
LOS ANGELES CA
90033-4201
US

IV. Provider business mailing address

1625 E 4TH ST
LOS ANGELES CA
90033-4201
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-8391
  • Fax: 323-268-8014
Mailing address:
  • Phone: 323-268-8391
  • Fax: 323-268-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA28934
License Number StateCA

VIII. Authorized Official

Name: MRS. CHRISTINE BARNES-KEITH
Title or Position: ADMINISTRATOR
Credential:
Phone: 323-268-8391