Healthcare Provider Details

I. General information

NPI: 1114543113
Provider Name (Legal Business Name): SERRA COMMUNITY MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8426 SUNLAND BLVD
SUN VALLEY CA
91352-3436
US

IV. Provider business mailing address

9375 SAN FERNANDO RD
SUN VALLEY CA
91352-1418
US

V. Phone/Fax

Practice location:
  • Phone: 818-504-4526
  • Fax: 818-504-4690
Mailing address:
  • Phone: 818-504-4700
  • Fax: 818-504-4690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LILY PEREZ
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 818-504-4701