Provider Demographics
NPI:1093966822
Name:ST NAZARENE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:ST NAZARENE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-989-0145
Mailing Address - Street 1:2403 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-3221
Mailing Address - Country:US
Mailing Address - Phone:562-989-0145
Mailing Address - Fax:562-989-2135
Practice Address - Street 1:2403 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-3221
Practice Address - Country:US
Practice Address - Phone:562-989-0145
Practice Address - Fax:562-989-2135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST NAZARENE MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055383261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14367Medicare UPIN