Healthcare Provider Details

I. General information

NPI: 1265489751
Provider Name (Legal Business Name): LOS ANGELES CLINICA MEDICA GENERAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 W 7TH ST
LOS ANGELES CA
90057-4002
US

IV. Provider business mailing address

PO BOX 10432
BEVERLY HILLS CA
90213-3432
US

V. Phone/Fax

Practice location:
  • Phone: 213-384-3434
  • Fax: 213-386-2039
Mailing address:
  • Phone: 213-637-2530
  • Fax: 231-384-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSE LUIS CARRILLO JR.
Title or Position: BUSINESS ACCOUNTS MANAGER
Credential:
Phone: 213-739-3282