=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386357697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S & J MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2023
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3710 E CESAR E CHAVEZ AVE STE 201
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90063-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-406-2204
-----------------------------------------------------
Fax | 323-406-2327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3710 E CESAR E CHAVEZ AVE STE 201
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90063-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-406-2204
-----------------------------------------------------
Fax | 323-406-2327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | PATRICIA FERNANDEZ
-----------------------------------------------------
Credential | OFFICE MANAGER
-----------------------------------------------------
Telephone | 323-406-2204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------