Provider Demographics
NPI:1114084092
Name:GUIAMELON MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:GUIAMELON MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RITA
Authorized Official - Middle Name:PARAISO
Authorized Official - Last Name:GUIAMELON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-426-0649
Mailing Address - Street 1:6130 BONNER AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4918
Mailing Address - Country:US
Mailing Address - Phone:818-980-6749
Mailing Address - Fax:818-980-6749
Practice Address - Street 1:7301 SEPULVEDA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1782
Practice Address - Country:US
Practice Address - Phone:818-786-7710
Practice Address - Fax:818-786-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84265208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84265OtherMEDICAL LICENSE
NY232930OtherMEDICAL LICENSE
CA00A842650OtherMEDI-CAL PROVIDER NUMBER
WA025209 MD00040515OtherMEDICAL LICENSE
CA00A842650OtherMEDI-CAL PROVIDER NUMBER
WA025209 MD00040515OtherMEDICAL LICENSE
CAW19696Medicare ID - Type UnspecifiedMEDICARE GROUP ID