MEDICARE: PIPELINE COMMUNITY SPECIALTY CLINIC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1053082586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIPELINE COMMUNITY SPECIALTY CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 80717
Second Line	:
City	:	CITY OF INDUSTRY
State	:	CA
Zip	:	91716-8416
Country	:	US
Telephone Number	:	310-321-0143
Fax Number	:	310-379-4856

Provider Business Practice Location Address
First Line	:	1141 W REDONDO BEACH BLVD STE 212
Second Line	:
City	:	GARDENA
State	:	CA
Zip	:	90247-3584
Country	:	US
Telephone Number	:	310-698-5463
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	VINCENT GREEN
Credential	:	MD
Telephone Number	:	310-321-0143

Provider Enumeration Date	:	09/23/2021
Last Update Date	:	01/25/2023

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Directions to “PIPELINE COMMUNITY SPECIALTY CLINIC ” Practice Location

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