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?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)