Provider Demographics
NPI:1114222130
Name:CLINICA LOS REMEDIOS PEDIATRIC FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:CLINICA LOS REMEDIOS PEDIATRIC FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:LIMPIN
Authorized Official - Last Name:MAKABALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-389-9595
Mailing Address - Street 1:2400 W 7TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-5008
Mailing Address - Country:US
Mailing Address - Phone:213-389-9595
Mailing Address - Fax:213-389-2556
Practice Address - Street 1:2400 W 7TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-5008
Practice Address - Country:US
Practice Address - Phone:213-389-9595
Practice Address - Fax:213-389-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-22
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065990Medicaid