=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093028896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA MARIA CLINICA FAMILIAR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2010
-----------------------------------------------------
Last Update Date | 03/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 N HARBOR BLVD
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-4847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-266-3032
-----------------------------------------------------
Fax | 562-266-3036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 N HARBOR BLVD
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-4847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-266-3032
-----------------------------------------------------
Fax | 562-266-3036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DELIA RAMIREZ
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 562-266-3032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A105315
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA12479
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------