MEDICARE: LAGUNA BEACH COMMUNITY CLINIC, 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	261QC1500X	Community Health Clinic/Center	596420	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EAP11948F	OTHER	CA	EAPC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225149222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAGUNA BEACH COMMUNITY CLINIC, INC.

Provider Business Mailing Address
First Line	:	362 3RD ST
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2307
Country	:	US
Telephone Number	:	949-494-0761
Fax Number	:	949-494-3154

Provider Business Practice Location Address
First Line	:	362 3RD ST
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2307
Country	:	US
Telephone Number	:	949-494-0761
Fax Number	:	949-494-3154

Authorized Official
Title or Position	:	CEO/CMO
Name	:	JORGE RUBAL
Credential	:	M.D., M.B.A
Telephone Number	:	949-494-0761

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	02/26/2025

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