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General NPI Number Information
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NPI Number | 1063927564
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Entity Type | Organization
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Legal Business Name | NORTHEAST COMMUNITY CLINIC
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Dates
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Enumeration Date | 12/06/2017
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Last Update Date | 10/15/2021
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Provider Practice Location Address
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Address Line | 1414 S GRAND AVE STE 456
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City | LOS ANGELES
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State | CA
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Zip | 90015-3071
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Country | US
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Telephone | 213-745-6047
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Fax | 213-748-9715
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Provider Business Mailing Address
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Address Line | 2550 W MAIN ST STE 301
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City | ALHAMBRA
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State | CA
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Zip | 91801-7003
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Country | US
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Telephone | 626-457-6900
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Fax | 626-457-5022
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. CHRISTOPHER TAK LAU
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Credential | MD
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Telephone | 626-457-6900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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