Healthcare Provider Details

I. General information

NPI: 1124208087
Provider Name (Legal Business Name): AUTUMN MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 COLIMA RD SUITE 207
WHITTIER CA
90605-1814
US

IV. Provider business mailing address

9200 COLIMA RD SUITE 207
WHITTIER CA
90605-1814
US

V. Phone/Fax

Practice location:
  • Phone: 562-945-0252
  • Fax: 562-945-0901
Mailing address:
  • Phone: 562-945-0252
  • Fax: 562-945-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA84718
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA25926
License Number StateCA

VIII. Authorized Official

Name: DR. MEHRUNISA MOHAMMEDI
Title or Position: CEO
Credential: M.D.
Phone: 562-945-0252