Healthcare Provider Details

I. General information

NPI: 1992246979
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 W. OLYMPIC BLVD.,
LOS ANGELES CA
90006-2810
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 Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number960001162
License Number StateCA

VIII. Authorized Official

Name: NIK GUPTA
Title or Position: CEO
Credential:
Phone: 818-895-3100