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General NPI Number Information
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NPI Number | 1992970016
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Entity Type | Organization
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Legal Business Name | SAN ANTONIO INGLEWOOD MEDICAL CLINIC INC
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Dates
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Enumeration Date | 04/29/2008
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Last Update Date | 04/30/2008
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Provider Practice Location Address
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Address Line | 10811 S GREVILLEA AVE
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City | LENNOX
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State | CA
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Zip | 90304-2325
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Country | US
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Telephone | 310-673-1922
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Fax | 310-673-7701
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Provider Business Mailing Address
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Address Line | 10811 S GREVILLEA AVE
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City | LENNOX
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State | CA
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Zip | 90304-2325
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Country | US
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Telephone | 310-673-1922
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Fax | 310-673-7701
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Authorized Official
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Title or Position | DIRECTOR
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Name | THOMAS GERKE
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Credential | M.D
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Telephone | 310-673-1922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | GO59290
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License Number State | CA
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