Healthcare Provider Details

I. General information

NPI: 1790901361
Provider Name (Legal Business Name): MC MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 IMPERIAL HWY SUITE 102
NORWALK CA
90650-3081
US

IV. Provider business mailing address

12100 IMPERIAL HWY SUITE 102
NORWALK CA
90650-3081
US

V. Phone/Fax

Practice location:
  • Phone: 562-929-4894
  • Fax: 562-929-6555
Mailing address:
  • Phone: 562-929-4894
  • Fax: 562-929-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA37955
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberA37955
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberA37955
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberA37955
License Number StateCA

VIII. Authorized Official

Name: DR. MELCHOR COLLANTES
Title or Position: DOCTOR
Credential: M.D.
Phone: 562-929-4894