Provider Demographics
NPI:1053507822
Name:TRADITIONAL FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:TRADITIONAL FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUDMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:AFONICHEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-328-2146
Mailing Address - Street 1:2204 TORRANCE BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2544
Mailing Address - Country:US
Mailing Address - Phone:310-328-2146
Mailing Address - Fax:310-328-2242
Practice Address - Street 1:2204 TORRANCE BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2544
Practice Address - Country:US
Practice Address - Phone:310-328-2146
Practice Address - Fax:310-328-2242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW17913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17913Medicare PIN
CAI00831Medicare UPIN