MEDICARE: ST ANTOINE DE PADOUE HEALTH CLINIC CORP.

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	261Q00000X	Clinic/Center	BU21412090	CA
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1376929828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST ANTOINE DE PADOUE HEALTH CLINIC CORP.

Provider Business Mailing Address
First Line	:	127 W 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-4344
Country	:	US
Telephone Number	:	562-977-5715
Fax Number	:	562-977-5715

Provider Business Practice Location Address
First Line	:	127 W 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-4344
Country	:	US
Telephone Number	:	562-324-6901
Fax Number	:	562-977-5715

Authorized Official
Title or Position	:	CEO
Name	:	BERGERETTE SAINT-VICTOR
Credential	:	FNP
Telephone Number	:	562-977-5715

Provider Enumeration Date	:	08/07/2015
Last Update Date	:	10/15/2015

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