Healthcare Provider Details

I. General information

NPI: 1215953609
Provider Name (Legal Business Name): SAN MARTIN DE PORRES MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 TELEGRAPH RD
PICO RIVERA CA
90660-5424
US

IV. Provider business mailing address

9315 TELEGRAPH RD
PICO RIVERA CA
90660-5424
US

V. Phone/Fax

Practice location:
  • Phone: 562-654-6855
  • Fax: 562-654-6856
Mailing address:
  • Phone: 562-654-6855
  • Fax: 562-654-6856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA24482
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierZZZ80011Z
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: FRANCISCO EDGARDO PAREDES
Title or Position: OWNER
Credential: M.D.
Phone: 562-654-6855