Healthcare Provider Details

I. General information

NPI: 1235738782
Provider Name (Legal Business Name): PENINSULA HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2020
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22330 HAWTHORNE BLVD STE 208
TORRANCE CA
90505-2536
US

IV. Provider business mailing address

22330 HAWTHORNE BLVD STE 208
TORRANCE CA
90505-2536
US

V. Phone/Fax

Practice location:
  • Phone: 877-354-1171
  • Fax: 424-488-3600
Mailing address:
  • Phone: 877-354-1171
  • Fax: 424-488-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHELLY CALHOUN
Title or Position: CEO
Credential: NP
Phone: 877-354-1171