=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467902106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEVERLY URGENT CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2016
-----------------------------------------------------
Last Update Date | 11/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 W BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-477-2200
-----------------------------------------------------
Fax | 323-597-1305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 W BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-477-2200
-----------------------------------------------------
Fax | 323-597-1305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | LORENZO ANGELES BRIONES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-477-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | A 39376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number | A 39376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | A 39376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------