MEDICARE: VENICE FAMILY 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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1639949191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VENICE FAMILY CLINIC

Provider Business Mailing Address
First Line	:	604 ROSE AVE
Second Line	:
City	:	VENICE
State	:	CA
Zip	:	90291-2767
Country	:	US
Telephone Number	:	310-392-8636
Fax Number	:

Provider Business Practice Location Address
First Line	:	514 N PROSPECT AVE STE 400
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3040
Country	:	US
Telephone Number	:	310-392-8636
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. MITESH G POPAT
Credential	:	MD
Telephone Number	:	310-664-7901

Provider Enumeration Date	:	01/05/2024
Last Update Date	:	01/05/2024

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Directions to “VENICE FAMILY CLINIC ” Practice Location

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