Provider Demographics
NPI:1114062163
Name:CENTRO MEDICO SANTA CRUZ MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:CENTRO MEDICO SANTA CRUZ MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VELMA
Authorized Official - Middle Name:ESTELLA
Authorized Official - Last Name:VISCARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-440-7901
Mailing Address - Street 1:8534 ROSECRANS AVE.
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723
Mailing Address - Country:US
Mailing Address - Phone:562-602-8877
Mailing Address - Fax:562-602-8844
Practice Address - Street 1:8534 ROSECRANS AVE.
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723
Practice Address - Country:US
Practice Address - Phone:562-602-8877
Practice Address - Fax:562-602-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34431OtherMEDICAL BOARD CALIFORNIA
CAA84627Medicare UPIN
CAGT262AMedicare Oscar/Certification