Provider Demographics
NPI:1003053943
Name:GAGE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:GAGE MEDICAL CLINIC INC
Other - Org Name:CLINICA VIRGEN DE GUADALUPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ODILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-706-2433
Mailing Address - Street 1:985 W VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3038
Mailing Address - Country:US
Mailing Address - Phone:323-234-6300
Mailing Address - Fax:
Practice Address - Street 1:985 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3038
Practice Address - Country:US
Practice Address - Phone:323-234-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GAGE MAEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-14
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29047207Q00000X, 207V00000X
CANP437634207Q00000X
CAPA19004207Q00000X, 207V00000X
CAPA18238207Q00000X, 207V00000X
CAPA17459207Q00000X, 207V00000X
CAPA20034207Q00000X, 207V00000X
CAA67659207Q00000X, 207V00000X
CARN437634207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty