Provider Demographics
NPI:1245785179
Name:VA MEDICAL CENTER
Entity Type:Organization
Organization Name:VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-500-0430
Mailing Address - Street 1:5939 CEDROS AVE APT A
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5939 CEDROS AVE APT A
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-3104
Practice Address - Country:US
Practice Address - Phone:310-500-0430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004376286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital