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General NPI Number Information
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NPI Number | 1891026100
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Entity Type | Organization
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Legal Business Name | ST NICHOLAS MEDICAL GROUP
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Dates
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Enumeration Date | 01/26/2010
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 5520 SANTA MONICA BLVD SUITE 112
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City | LOS ANGELES
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State | CA
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Zip | 90038-2932
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Country | US
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Telephone | 323-860-9054
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Fax | 323-860-9053
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Provider Business Mailing Address
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Address Line | 5520 SANTA MONICA BLVD SUITE 112
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City | LOS ANGELES
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State | CA
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Zip | 90038-2932
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Country | US
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Telephone | 323-860-9054
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Fax | 323-860-9053
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Authorized Official
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Title or Position | PARTNER
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Name | DR. JACOB N FLORES
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Credential | MD
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Telephone | 323-860-9054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | A60865
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License Number State | CA
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