Provider Demographics
NPI:1144382938
Name:CAVALES ASTHMA ALLERGY MEDICAL CLINIC,INC
Entity Type:Organization
Organization Name:CAVALES ASTHMA ALLERGY MEDICAL CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:CAVALES
Authorized Official - Last Name:OFTADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-582-5458
Mailing Address - Street 1:PO BOX 3925
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-3925
Mailing Address - Country:US
Mailing Address - Phone:323-582-5458
Mailing Address - Fax:323-835-1475
Practice Address - Street 1:4566 FLORENCE AVE STE 4
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:CA
Practice Address - Zip Code:90201-4346
Practice Address - Country:US
Practice Address - Phone:323-582-5458
Practice Address - Fax:323-835-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50327174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A50327Medicaid
CA00A50327Medicaid
CAW17322Medicare ID - Type Unspecified