Provider Demographics
NPI:1043476609
Name:QUEENSCARE FAMILY CLINICS
Entity Type:Organization
Organization Name:QUEENSCARE FAMILY CLINICS
Other - Org Name:QUEENSCARE FAMILY CLINICS - MENTAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ALLEN
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 809
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6005
Mailing Address - Country:US
Mailing Address - Phone:323-669-4355
Mailing Address - Fax:
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:SUITE 809
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-669-4355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)