=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114053279
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAGE MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2007
-----------------------------------------------------
Last Update Date | 02/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13563 VAN NUYS BLVD
-----------------------------------------------------
City | PACOIMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91331-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-890-5300
-----------------------------------------------------
Fax | 818-890-0880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13563 VAN NUYS BLVD
-----------------------------------------------------
City | PACOIMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91331-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-890-5300
-----------------------------------------------------
Fax | 818-890-0880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ODILIA WALSH
-----------------------------------------------------
Credential | ADMINISTRATOR
-----------------------------------------------------
Telephone | 562-706-2433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G29047
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | A67946
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A47748
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------