Provider Demographics
NPI:1073832887
Name:INGLEWOOD FAMILY MEDICAL CLINIC CORP
Entity Type:Organization
Organization Name:INGLEWOOD FAMILY MEDICAL CLINIC CORP
Other - Org Name:INGLEWOOD FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC/TRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:DEANNA
Authorized Official - Last Name:RILEY-GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:310-677-3595
Mailing Address - Street 1:3215 W IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2810
Mailing Address - Country:US
Mailing Address - Phone:310-677-3595
Mailing Address - Fax:310-355-8373
Practice Address - Street 1:3215 W IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-2810
Practice Address - Country:US
Practice Address - Phone:310-677-3595
Practice Address - Fax:310-355-8373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61290207Q00000X
CAPA14869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty