Healthcare Provider Details

I. General information

NPI: 1104813146
Provider Name (Legal Business Name): QUEENS CARE FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N RENO ST
LOS ANGELES CA
90026-4656
US

IV. Provider business mailing address

150 N RENO ST
LOS ANGELES CA
90026-4656
US

V. Phone/Fax

Practice location:
  • Phone: 213-380-7298
  • Fax: 213-384-0951
Mailing address:
  • Phone: 213-380-7298
  • Fax: 213-384-0951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number510678
License Number StateCA

VIII. Authorized Official

Name: MS. PAULA L SITU
Title or Position: FAMILY NURSE PRACTITIONER
Credential: MSN
Phone: 213-380-7298