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General NPI Number Information
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NPI Number | 1841500253
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Entity Type | Organization
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Legal Business Name | EASTSIDE DIABETES CARE MEDICAL CLINIC, INC.
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Dates
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Enumeration Date | 10/19/2010
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Last Update Date | 02/27/2015
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Provider Practice Location Address
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Address Line | 5836 E BEVERLY BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90022-2824
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Country | US
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Telephone | 323-726-0370
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Fax | 323-726-0239
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Provider Business Mailing Address
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Address Line | 5836 E BEVERLY BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90022-2824
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Country | US
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Telephone | 323-726-0370
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Fax | 323-726-0239
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. ALTAGRACIA A RODRIGUEZ
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Credential |
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Telephone | 323-726-0370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | A33652
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A33652
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License Number State | CA
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