Provider Demographics
NPI:1174658322
Name:CLINICA MEDICA CENTRO LASER HISPANO INC.
Entity Type:Organization
Organization Name:CLINICA MEDICA CENTRO LASER HISPANO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:RIFKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:909-467-1445
Mailing Address - Street 1:1341 E 4TH ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-3034
Mailing Address - Country:US
Mailing Address - Phone:909-467-1445
Mailing Address - Fax:909-467-1446
Practice Address - Street 1:1341 E 4TH ST
Practice Address - Street 2:UNIT B
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-3034
Practice Address - Country:US
Practice Address - Phone:909-467-1445
Practice Address - Fax:909-467-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32553208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325530OtherBLUE CROSS BLUE SHIELD
CAZZZ01997ZMedicare ID - Type UnspecifiedONTARIO GROUP NUMBER
CA00A325531Medicare ID - Type UnspecifiedPPIN ONTARIO LOC
CA00A325530OtherBLUE CROSS BLUE SHIELD