MEDICARE: DOROTHY MAE MEDICAL CLINIC INC.

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	261QP2300X	Primary Care Clinic/Center	A064610	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W14542	OTHER	CA	GROUP PTAN

General Provider Information

NPI Number	:	1669533907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOROTHY MAE MEDICAL CLINIC INC.

Provider Business Mailing Address
First Line	:	PO BOX 5167
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92052-5167
Country	:	US
Telephone Number	:	323-750-1196
Fax Number	:	323-750-0330

Provider Business Practice Location Address
First Line	:	8880 S BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90003-3635
Country	:	US
Telephone Number	:	323-750-1196
Fax Number	:	323-750-0330

Authorized Official
Title or Position	:	CEO
Name	:	DR. MICHAEL JEROME SINGLETON
Credential	:	M.D.
Telephone Number	:	310-600-6046

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	03/31/2016

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