MEDICARE: ST NICHOLAS MEDICAL GROUP

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	A60865	CA

General Provider Information

NPI Number	:	1891026100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST NICHOLAS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	5520 SANTA MONICA BLVD
Second Line	:	SUITE 112
City	:	LOS ANGELES
State	:	CA
Zip	:	90038-2932
Country	:	US
Telephone Number	:	323-860-9054
Fax Number	:	323-860-9053

Provider Business Practice Location Address
First Line	:	5520 SANTA MONICA BLVD
Second Line	:	SUITE 112
City	:	LOS ANGELES
State	:	CA
Zip	:	90038-2932
Country	:	US
Telephone Number	:	323-860-9054
Fax Number	:	323-860-9053

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. JACOB N FLORES
Credential	:	MD
Telephone Number	:	323-860-9054

Provider Enumeration Date	:	01/26/2010
Last Update Date	:	08/26/2010

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