MEDICARE: LOS REYES CLINICA MEDICA, 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	207RI0011X	Interventional Cardiology Physician
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1952461774	OTHER	CA	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265740930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOS REYES CLINICA MEDICA, INC.

Provider Business Mailing Address
First Line	:	6007 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-4401
Country	:	US
Telephone Number	:	323-725-1144
Fax Number	:	323-583-0012

Provider Business Practice Location Address
First Line	:	6007 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-4401
Country	:	US
Telephone Number	:	323-725-1144
Fax Number	:	323-583-0012

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MYRA GOMEZ
Credential	:
Telephone Number	:	323-725-1144

Provider Enumeration Date	:	09/15/2010
Last Update Date	:	09/15/2010

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