Healthcare Provider Details

I. General information

NPI: 1154887560
Provider Name (Legal Business Name): SAMARITANA MEDICAL CLINIC,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4149 TWEEDY BLVD STE B
SOUTH GATE CA
90280-6167
US

IV. Provider business mailing address

2661 E FLORENCE AVE STE B
HUNTINGTON PARK CA
90255-4793
US

V. Phone/Fax

Practice location:
  • Phone: 323-825-0180
  • Fax: 877-340-3470
Mailing address:
  • Phone: 323-583-3375
  • Fax: 877-340-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RUDY MARTINEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 213-483-3600