Healthcare Provider Details

I. General information

NPI: 1811141021
Provider Name (Legal Business Name): SOUTHLANDS MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8614 VAN NUYS BLVD
PANORAMA CITY CA
91402-2913
US

IV. Provider business mailing address

17171 ROSCOE BLVD SUITE F215
NORTHRIDGE CA
91325-4060
US

V. Phone/Fax

Practice location:
  • Phone: 818-913-9551
  • Fax: 818-647-6310
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA 98001
License Number StateCA

VIII. Authorized Official

Name: DR. PADMAJA REDDY KANKAR
Title or Position: PRESIDENT
Credential: MD
Phone: 818-913-9551