Healthcare Provider Details

I. General information

NPI: 1326317595
Provider Name (Legal Business Name): CLOVER MEDICAL CORPORATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2011
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12134 VICTORY BLVD SUITE C
NORTH HOLLYWOOD CA
91606-3205
US

IV. Provider business mailing address

12134 VICTORY BLVD SUITE C
NORTH HOLLYWOOD CA
91606-3205
US

V. Phone/Fax

Practice location:
  • Phone: 818-762-8702
  • Fax: 818-761-2583
Mailing address:
  • Phone: 818-762-8702
  • Fax: 818-761-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MITCH RUBIN
Title or Position: PRESIDENT
Credential:
Phone: 818-762-8702