Provider Demographics
NPI:1073534608
Name:SAN GABRIEL HEALTH CLINIC
Entity Type:Organization
Organization Name:SAN GABRIEL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BO
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-288-2007
Mailing Address - Street 1:2630 SAN GABRIEL BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-5204
Mailing Address - Country:US
Mailing Address - Phone:626-288-2007
Mailing Address - Fax:626-288-2116
Practice Address - Street 1:2630 SAN GABRIEL BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-5204
Practice Address - Country:US
Practice Address - Phone:626-288-2007
Practice Address - Fax:626-288-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP34454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFNP34454OtherFICTITIOUS BUSINESS #
CAGR0102390Medicaid
CAGR0102390Medicaid