Healthcare Provider Details

I. General information

NPI: 1194846410
Provider Name (Legal Business Name): PRAIRIE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4644 LINCOLN BLVD SUITE 428
MARINA DEL REY CA
90292
US

IV. Provider business mailing address

DEPT 2834
LOS ANGELES CA
90084
US

V. Phone/Fax

Practice location:
  • Phone: 310-214-8677
  • Fax: 310-921-1718
Mailing address:
  • Phone: 310-306-1888
  • Fax: 310-577-8290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number058963
License Number StateCA

VIII. Authorized Official

Name: CHRISTOPHER C CHIDI
Title or Position: PRESIDENT
Credential: MD
Phone: 310-214-8677