Healthcare Provider Details

I. General information

NPI: 1619700200
Provider Name (Legal Business Name): UNIVERSITY MUSLIM MEDICAL ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7821 AVALON BLVD
LOS ANGELES CA
90003-2358
US

IV. Provider business mailing address

6814 PACIFIC BLVD
HUNTINGTON PARK CA
90255-4197
US

V. Phone/Fax

Practice location:
  • Phone: 323-789-5610
  • Fax: 323-789-5616
Mailing address:
  • Phone: 323-789-5610
  • Fax: 323-789-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental 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