Healthcare Provider Details

I. General information

NPI: 1316164908
Provider Name (Legal Business Name): ERIC MCCLOUD MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23560 MADISON ST SUITE 206
TORRANCE CA
90505-4708
US

IV. Provider business mailing address

23560 MADISON ST SUITE 206
TORRANCE CA
90505-4708
US

V. Phone/Fax

Practice location:
  • Phone: 310-325-1229
  • Fax: 310-325-1233
Mailing address:
  • Phone: 310-325-1229
  • Fax: 310-325-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberG61054
License Number StateCA

VIII. Authorized Official

Name: ERIC MCCLOUD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-325-1229