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General NPI Number Information
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NPI Number | 1619343118
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Entity Type | Organization
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Legal Business Name | VENICE FAMILY CLINIC
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Dates
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Enumeration Date | 08/19/2015
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Last Update Date | 09/09/2015
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Provider Practice Location Address
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Address Line | 2509 PICO BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90405-1828
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Country | US
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Telephone | 310-664-7878
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Fax |
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Provider Business Mailing Address
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Address Line | 604 ROSE AVE
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City | VENICE
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State | CA
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Zip | 90291-2767
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ELIZABETH BENSON FORER
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Credential |
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Telephone | 310-664-7901
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | HY13130
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License Number State | CA
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