Provider Demographics
NPI:1073791828
Name:LA LIBERTAD MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:LA LIBERTAD MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHAMBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-585-2486
Mailing Address - Street 1:PO BOX 3429
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2329
Mailing Address - Country:US
Mailing Address - Phone:323-585-2486
Mailing Address - Fax:562-943-7518
Practice Address - Street 1:8427 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2014
Practice Address - Country:US
Practice Address - Phone:323-585-2486
Practice Address - Fax:562-943-7518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA LIBERTAD MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-04
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101040Medicaid
CACB246929Medicare PIN