Healthcare Provider Details

I. General information

NPI: 1518996313
Provider Name (Legal Business Name): CONSULTORIO MEDICO LATINO MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15730 PARAMOUNT BLVD
PARAMOUNT CA
90723-4333
US

IV. Provider business mailing address

PO BOX 829
PARAMOUNT CA
90723-0829
US

V. Phone/Fax

Practice location:
  • Phone: 562-634-1000
  • Fax: 562-634-3048
Mailing address:
  • Phone: 562-634-1000
  • Fax: 562-634-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA48328
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA48328
License Number StateCA

VIII. Authorized Official

Name: MR. BEHROOZ BRUCE YAGOOBIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 562-634-1000