MEDICARE: LINCOLN HEIGHTS URGENT CARE

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	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053789776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN HEIGHTS URGENT CARE

Provider Business Mailing Address
First Line	:	2813 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2813 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2611
Country	:	US
Telephone Number	:	323-342-9764
Fax Number	:	323-342-9656

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TOMAS A SEVILLA
Credential	:	M.D.
Telephone Number	:	323-342-9764

Provider Enumeration Date	:	09/11/2015
Last Update Date	:	09/12/2015

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