Provider Demographics
NPI:1023033818
Name:FOUR SEASON CLINIC
Entity Type:Organization
Organization Name:FOUR SEASON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANASYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-842-0626
Mailing Address - Street 1:PO BOX 5046
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-9046
Mailing Address - Country:US
Mailing Address - Phone:323-842-0626
Mailing Address - Fax:323-588-9994
Practice Address - Street 1:5900 PACIFIC BLVD
Practice Address - Street 2:SUITE 202A
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2914
Practice Address - Country:US
Practice Address - Phone:323-842-0626
Practice Address - Fax:323-588-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36991170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19433Medicare ID - Type Unspecified