Healthcare Provider Details

I. General information

NPI: 1558746776
Provider Name (Legal Business Name): PRIME MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24241 HAWTHORNE BLVD SUITE 201
TORRANCE CA
90505-6504
US

IV. Provider business mailing address

24241 HAWTHORNE BLVD SUITE 201
TORRANCE CA
90505-6504
US

V. Phone/Fax

Practice location:
  • Phone: 310-602-5484
  • Fax:
Mailing address:
  • Phone: 310-602-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A6453
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberRHF00073209
License Number StateCA

VIII. Authorized Official

Name: ALEJANDRO GONZALEZ
Title or Position: OWNER
Credential: D.O.
Phone: 626-664-1279