Provider Demographics
NPI:1114053279
Name:GAGE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:GAGE MEDICAL CLINIC INC
Other - Org Name:PACOIMA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ODILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:562-706-2433
Mailing Address - Street 1:13563 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-3029
Mailing Address - Country:US
Mailing Address - Phone:818-890-5300
Mailing Address - Fax:818-890-0880
Practice Address - Street 1:13563 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-3029
Practice Address - Country:US
Practice Address - Phone:818-890-5300
Practice Address - Fax:818-890-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29047207Q00000X, 207Q00000X
CAA47748207Q00000X, 207V00000X
CAA67946207V00000X, 207V00000X, 207V00000X
261QM1300X, 207Q00000X, 261QM1300X
CAPA17459207V00000X
CAPA15565207V00000X
CARN437634207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102050Medicaid
CAGR0102050Medicaid
CAA43942Medicare UPIN