Provider Demographics
NPI:1114543113
Name:SERRA COMMUNITY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:SERRA COMMUNITY MEDICAL CLINIC, INC.
Other - Org Name:SERRA COMMUNITY MEDICAL CLINIC- SUNLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-504-4701
Mailing Address - Street 1:9375 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-1418
Mailing Address - Country:US
Mailing Address - Phone:818-504-4700
Mailing Address - Fax:818-504-4690
Practice Address - Street 1:8426 SUNLAND BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3436
Practice Address - Country:US
Practice Address - Phone:818-504-4526
Practice Address - Fax:818-504-4690
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERRA COMMUNITY MEDICAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-25
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275545725Medicaid