MEDICARE: SALIDA DEL SOL CBAS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1013795020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALIDA DEL SOL CBAS, LLC

Provider Business Mailing Address
First Line	:	5350 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-6020
Country	:	US
Telephone Number	:	562-269-4355
Fax Number	:

Provider Business Practice Location Address
First Line	:	5350 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-6020
Country	:	US
Telephone Number	:	562-269-4355
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BOYU LIU
Credential	:
Telephone Number	:	949-561-0999

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	09/20/2023

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