Provider Demographics
NPI: | 1053854836 |
---|---|
Name: | VENICE FAMILY CLINIC |
Entity Type: | Organization |
Organization Name: | VENICE FAMILY CLINIC |
Other - Org Name: | BILL'S CLINIC AT SAFE PLACE FOR YOUTH |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | CHIEF EXECUTIVE OFFICER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MITESH |
Authorized Official - Middle Name: | G |
Authorized Official - Last Name: | POPAT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 310-664-7901 |
Mailing Address - Street 1: | 604 ROSE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | VENICE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90291-2767 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-392-8636 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2469 LINCOLN BLVD |
Practice Address - Street 2: | |
Practice Address - City: | VENICE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90291-5040 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-392-8636 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | VENICE FAMILY CLINIC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2016-11-28 |
Last Update Date: | 2023-09-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |