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General NPI Number Information
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NPI Number | 1891134268
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Entity Type | Organization
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Legal Business Name | PRIMARY CARE HEALTH CLINIC
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Dates
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Enumeration Date | 06/19/2013
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Last Update Date | 01/13/2016
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Provider Practice Location Address
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Address Line | 1601 W WASHINGTON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90007-1116
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Country | US
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Telephone | 310-701-6703
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 W WASHINGTON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90007-1116
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Country | US
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Telephone | 310-701-6703
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. NDIKA FOMUKONG
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Credential | NP
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Telephone | 310-701-6703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 34954
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 34954
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 34954
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 34954
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34954
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License Number State | CA
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