MEDICARE: LA PROVIDENCIA 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1609061431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA PROVIDENCIA MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	3412 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023
Country	:	US
Telephone Number	:	323-264-4006
Fax Number	:	323-264-4052

Provider Business Practice Location Address
First Line	:	3412 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023
Country	:	US
Telephone Number	:	323-264-4006
Fax Number	:	323-264-4052

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. SAMUEL WOSK
Credential	:	MD
Telephone Number	:	323-264-4006

Provider Enumeration Date	:	09/14/2007
Last Update Date	:	09/14/2007

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Directions to “LA PROVIDENCIA MEDICAL CLINIC ” Practice Location

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