MEDICARE: CLINICA DEL SOCORRO MEDICAL GROUP,INC.

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	208D00000X	General Practice Physician	A20149	CA
2	207Q00000X	Family Medicine Physician	C39153	CA

General Provider Information

NPI Number	:	1215263827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA DEL SOCORRO MEDICAL GROUP,INC.

Provider Business Mailing Address
First Line	:	1061 E VERNON AVE
Second Line	:	SUITE 'F'
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-3772
Country	:	US
Telephone Number	:	323-233-9686
Fax Number	:	323-233-0595

Provider Business Practice Location Address
First Line	:	1061 E VERNON AVE
Second Line	:	SUITE 'F'
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-3772
Country	:	US
Telephone Number	:	323-233-9686
Fax Number	:	323-233-0595

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. PATRICK B. LAWRENCE
Credential	:	M.D.
Telephone Number	:	323-233-9686

Provider Enumeration Date	:	11/02/2009
Last Update Date	:	11/18/2009

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