Healthcare Provider Details

I. General information

NPI: 1114638723
Provider Name (Legal Business Name): UNIVERSITY MUSLIM MEDICAL ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W FLORENCE AVE
LOS ANGELES CA
90044-6105
US

IV. Provider business mailing address

711 W FLORENCE AVE
LOS ANGELES CA
90044-6105
US

V. Phone/Fax

Practice location:
  • Phone: 323-789-5610
  • Fax:
Mailing address:
  • Phone: 323-789-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ALFREDO REYNOSO
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 323-313-5588