Provider Demographics
NPI:1053677401
Name:QUEENSCARE HEALTH ALLIANCE
Entity Type:Organization
Organization Name:QUEENSCARE HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:B
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-669-4302
Mailing Address - Street 1:950 SOUTH GRAND AVE., 2ND FLOOR SOUTH
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015
Mailing Address - Country:US
Mailing Address - Phone:213-705-3906
Mailing Address - Fax:213-705-3906
Practice Address - Street 1:680 LITTLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1644
Practice Address - Country:US
Practice Address - Phone:323-715-1527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X, 1223P0221X
CA5500016481223P0221X
CA5500018251223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550001649OtherLICENSE NUMBER