Provider Demographics
NPI:1114231354
Name:SAN LUCAS MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:SAN LUCAS MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VITAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HINOJOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-521-9725
Mailing Address - Street 1:2010 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 2012
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3507
Mailing Address - Country:US
Mailing Address - Phone:213-989-1535
Mailing Address - Fax:213-989-1843
Practice Address - Street 1:2010 WILSHIRE BLVD
Practice Address - Street 2:SUITE 2012
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3507
Practice Address - Country:US
Practice Address - Phone:213-989-1535
Practice Address - Fax:213-989-1843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37463208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAED251AOtherMEDICARE PTAN
CA1396874202Medicaid
CA1396874202Medicaid
CAA37463AMedicare PIN