Healthcare Provider Details

I. General information

NPI: 1831456482
Provider Name (Legal Business Name): SAN MANUEL MEDICAL CLINIC,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 PACIFIC BLVD STE A
WALNUT PARK CA
90255-5739
US

IV. Provider business mailing address

7400 PACIFIC BLVD STE A
WALNUT PARK CA
90255-5739
US

V. Phone/Fax

Practice location:
  • Phone: 323-585-8881
  • Fax:
Mailing address:
  • Phone: 323-585-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA84082
License Number StateCA

VIII. Authorized Official

Name: ELIA WEBB
Title or Position: OFFICE MANAGER
Credential:
Phone: 323-585-8881