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General NPI Number Information
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NPI Number | 1083767875
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Entity Type | Organization
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Legal Business Name | NUEVA ESPERANZA HEALTHCARE MEDICAL CLINIC INC.
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 10/29/2020
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Provider Practice Location Address
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Address Line | 1704 W MANCHESTER AVE SUITE 109
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City | LOS ANGELES
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State | CA
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Zip | 90047-3034
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Country | US
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Telephone | 323-778-8485
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Fax |
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Provider Business Mailing Address
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Address Line | 1704 W MANCHESTER AVE STE 109
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City | LOS ANGELES
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State | CA
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Zip | 90047-3056
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Country | US
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Telephone | 323-778-8485
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AMANI ELDESSOUKY
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Credential |
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Telephone | 323-778-8485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A56426
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License Number State | CA
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