Healthcare Provider Details

I. General information

NPI: 1265093520
Provider Name (Legal Business Name): COMMUNITY CARE MEDICAL CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13118 SHERMAN WAY
NORTH HOLLYWOOD CA
91605
US

IV. Provider business mailing address

13118 SHERMAN WAY
NORTH HOLLYWOOD CA
91605
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-6318
  • Fax: 818-308-6373
Mailing address:
  • Phone: 818-308-6318
  • Fax: 818-308-6373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. WENDI M. RODRIGUEZ
Title or Position: CEO/ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 818-308-6318