Healthcare Provider Details

I. General information

NPI: 1275796278
Provider Name (Legal Business Name): GIRLFRIENDS MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S FAIR OAKS AVE
PASADENA CA
91105-2561
US

IV. Provider business mailing address

301 S FAIR OAKS AVE
PASADENA CA
91105-2561
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-5250
  • Fax: 626-793-5260
Mailing address:
  • Phone: 626-793-5250
  • Fax: 626-793-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA065104
License Number StateCA

VIII. Authorized Official

Name: MRS. LATANYA R HINES
Title or Position: M.D
Credential: M.D
Phone: 626-793-5250