=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477273340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLO MEDINA MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2022
-----------------------------------------------------
Last Update Date | 06/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 ADMIRALTY WAY STE 201
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-5425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-823-3443
-----------------------------------------------------
Fax | 310-305-7470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1626 MONTANA AVE # 631
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-1808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-893-0827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CARLO MEDINA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-312-6385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------