MEDICARE: NOVA MEDICAL CENTER

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	174400000X	Specialist	A64420	CA

General Provider Information

NPI Number	:	1326208877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA MEDICAL CENTER

Provider Business Mailing Address
First Line	:	PO BOX 942014
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93094-2014
Country	:	US
Telephone Number	:	818-843-1116
Fax Number	:

Provider Business Practice Location Address
First Line	:	1423 W 8TH ST
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90732-3803
Country	:	US
Telephone Number	:	818-599-1002
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. RANDALL CALDRON
Credential	:
Telephone Number	:	818-599-1002

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	04/03/2019

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Directions to “NOVA MEDICAL CENTER ” Practice Location

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