Healthcare Provider Details

I. General information

NPI: 1548740939
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 SANTA MONICA BLVD STE 202
LOS ANGELES CA
90029
US

IV. Provider business mailing address

8527 SEPULVEDA BLVD
NORTH HILLS CA
91343-5824
US

V. Phone/Fax

Practice location:
  • Phone: 818-895-3100
  • Fax: 818-893-9464
Mailing address:
  • Phone: 818-895-3100
  • Fax: 818-893-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number550001476
License Number StateCA

VIII. Authorized Official

Name: MR. NIK GUPTA
Title or Position: PRESIDENT/CEO
Credential:
Phone: 818-895-3100