MEDICARE: ATLANTIC AVENUE MEDICAL CLINIC

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	A35223	CA

General Provider Information

NPI Number	:	1477550788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC AVENUE MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 619
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-0619
Country	:	US
Telephone Number	:	323-562-3414
Fax Number	:	323-562-3100

Provider Business Practice Location Address
First Line	:	3737 MARTIN LUTHER KING JR BLVD STE 333
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-3528
Country	:	US
Telephone Number	:	323-562-3414
Fax Number	:	323-562-3100

Authorized Official
Title or Position	:	MD
Name	:	KEITH IVOR MOOTOO
Credential	:
Telephone Number	:	323-562-3414

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	10/16/2018

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