Healthcare Provider Details

I. General information

NPI: 1689073595
Provider Name (Legal Business Name): GOOD NEIGHBOR CLINIC A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 CRENSHAW BLVD.
LOS ANGELES CA
90008
US

IV. Provider business mailing address

1270 S ALFRED ST UNIT 1064
LOS ANGELES CA
90035-2506
US

V. Phone/Fax

Practice location:
  • Phone: 323-298-1668
  • Fax: 323-298-0458
Mailing address:
  • Phone: 310-212-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA31491
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANIEL SHANE SHEIBANI DAVIDSON
Title or Position: ADMINISTRATOR
Credential: MD, MBA, DBA
Phone: 310-212-1500