Provider Demographics
NPI:1114668647
Name:THE LOS ANGELES FREE CLINIC - MOBILE CLINIC
Entity Type:Organization
Organization Name:THE LOS ANGELES FREE CLINIC - MOBILE CLINIC
Other - Org Name:SABAN COMMUNITY CLINIC - MOBILE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MURIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOUWEZEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-337-1707
Mailing Address - Street 1:8405 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3401
Mailing Address - Country:US
Mailing Address - Phone:323-653-1990
Mailing Address - Fax:
Practice Address - Street 1:6043 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-5411
Practice Address - Country:US
Practice Address - Phone:323-653-1990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)