Healthcare Provider Details

I. General information

NPI: 1356914857
Provider Name (Legal Business Name): VENICE FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2114 ARTESIA BLVD
REDONDO BEACH CA
90278-3014
US

IV. Provider business mailing address

604 ROSE AVE
VENICE CA
90291-2767
US

V. Phone/Fax

Practice location:
  • Phone: 310-802-6177
  • Fax: 310-802-6178
Mailing address:
  • Phone: 310-392-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MITESH G POPAT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 310-664-7901