=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033326863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN PAUL II MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6529 SEVILLE AVE
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-5745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-582-5770
-----------------------------------------------------
Fax | 323-582-1103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 253
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-0253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-582-5770
-----------------------------------------------------
Fax | 323-582-1103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL WALDO VELASQUEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 323-582-5770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A052551
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------