=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083643837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORNINGSIDE PRIMARY CARE MEDICAL CTR, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 12/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1704 W MANCHESTER AVE SUITE 101
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-778-6215
-----------------------------------------------------
Fax | 323-778-6312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 W MANCHESTER AVE SUITE 101
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-778-6215
-----------------------------------------------------
Fax | 323-778-6312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. LEMMON C MCMILLAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-778-6215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------