Provider Demographics
NPI:1114560083
Name:SIN FRONTERAS HEALTH AND WELLNESS CENTER, INC, A PROFESSIONAL CORPORAT
Entity Type:Organization
Organization Name:SIN FRONTERAS HEALTH AND WELLNESS CENTER, INC, A PROFESSIONAL CORPORAT
Other - Org Name:SIN FRONTERAS HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-725-6292
Mailing Address - Street 1:6006 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4402
Mailing Address - Country:US
Mailing Address - Phone:323-725-6292
Mailing Address - Fax:323-725-6292
Practice Address - Street 1:6006 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4402
Practice Address - Country:US
Practice Address - Phone:323-725-6292
Practice Address - Fax:323-725-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G733840Medicaid