Healthcare Provider Details

I. General information

NPI: 1376888024
Provider Name (Legal Business Name): FLORENCE WESTERN MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 VAN NUYS BLVD
PACOIMA CA
91331-3028
US

IV. Provider business mailing address

7301 S WESTERN AVE
LOS ANGELES CA
90047-2254
US

V. Phone/Fax

Practice location:
  • Phone: 818-896-2999
  • Fax: 818-896-8449
Mailing address:
  • Phone: 818-896-2999
  • Fax: 818-896-8449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA52385
License Number StateCA

VIII. Authorized Official

Name: KEVIN CHARLES THOMAS
Title or Position: MD/OWNER
Credential: MD
Phone: 323-778-2131