Provider Demographics
NPI:1154457745
Name:ALISO MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:ALISO MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES-KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-268-8391
Mailing Address - Street 1:1625 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-4201
Mailing Address - Country:US
Mailing Address - Phone:323-268-8391
Mailing Address - Fax:323-268-8014
Practice Address - Street 1:1625 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4201
Practice Address - Country:US
Practice Address - Phone:323-268-8391
Practice Address - Fax:323-268-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA28934208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ74805ZOtherBLUE SHIELD GRP PIN
CAGR0067720Medicaid
CA00A289340Medicaid
CA11513273OtherCAQH ID
CAWA28934AMedicare ID - Type UnspecifiedMEDICARE NUMBER
CAZZZ74805ZOtherBLUE SHIELD GRP PIN
CA00A289340Medicaid
CAGR0067720Medicaid