Healthcare Provider Details

I. General information

NPI: 1669418513
Provider Name (Legal Business Name): VENICE FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 ROSE AVE
VENICE CA
90291-2767
US

IV. Provider business mailing address

604 ROSE AVE
VENICE CA
90291-2767
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-8636
  • Fax:
Mailing address:
  • Phone: 310-392-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number960000169
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. MITESH G POPAT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 310-664-7901