=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649086166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WALL LAS MEMORIAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 E 1ST ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-257-1056
-----------------------------------------------------
Fax | 323-529-0200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 W 6TH ST STE 750
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-257-1056
-----------------------------------------------------
Fax | 323-529-0200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR/FOUNDER
-----------------------------------------------------
Name | MR. RICHARD L. ZALDIVAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-257-1056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------