Provider Demographics
NPI:1043381213
Name:QUEENSCARE FAMILY CLINICS
Entity Type:Organization
Organization Name:QUEENSCARE FAMILY CLINICS
Other - Org Name:QUEENSCARE FAMILY CLINICS - WILSHIRE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BONECUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-669-4303
Mailing Address - Street 1:1300 N VERMONT AVE
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6005
Mailing Address - Country:US
Mailing Address - Phone:323-669-4303
Mailing Address - Fax:323-953-6244
Practice Address - Street 1:3242 W 8TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-2176
Practice Address - Country:US
Practice Address - Phone:213-368-9779
Practice Address - Fax:213-368-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001012261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551897Medicare Oscar/Certification