Provider Demographics
NPI:1245391564
Name:PICO UNION WOMEN'S HEALTH CLINIC
Entity Type:Organization
Organization Name:PICO UNION WOMEN'S HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMBALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-384-7629
Mailing Address - Street 1:1811 W PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-5006
Mailing Address - Country:US
Mailing Address - Phone:213-384-7629
Mailing Address - Fax:213-384-7630
Practice Address - Street 1:1811 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5006
Practice Address - Country:US
Practice Address - Phone:213-384-7629
Practice Address - Fax:213-384-7630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67608207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A676080Medicaid
CA00A676080Medicaid