Healthcare Provider Details

I. General information

NPI: 1275786402
Provider Name (Legal Business Name): MISSION CITY COMMUNITY NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8363 RESEDA BLVD STE 11
NORTHRIDGE CA
91324-4694
US

IV. Provider business mailing address

8527 SEPULVEDA BLVD
NORTH HILLS CA
91343-5824
US

V. Phone/Fax

Practice location:
  • Phone: 818-998-7085
  • Fax: 818-998-3579
Mailing address:
  • Phone: 818-895-3100
  • Fax: 818-892-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550000351
License Number StateCA

VIII. Authorized Official

Name: MR. NIK GUPTA
Title or Position: CHEIF EXECUTIVE OFFICER
Credential:
Phone: 818-895-3100