Provider Demographics
NPI:1255495552
Name:THE CHILDRENS CLINIC 'SERVING CHILDREN AND THEIR FAMILIES'
Entity Type:Organization
Organization Name:THE CHILDRENS CLINIC 'SERVING CHILDREN AND THEIR FAMILIES'
Other - Org Name:THE VASEK POLAK CHILDREN'S CLINIC FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:562-264-3985
Mailing Address - Street 1:701 E 28TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2759
Mailing Address - Country:US
Mailing Address - Phone:562-264-3985
Mailing Address - Fax:562-216-6197
Practice Address - Street 1:1057 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3118
Practice Address - Country:US
Practice Address - Phone:562-264-4668
Practice Address - Fax:562-366-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001379261QC1500X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70992FMedicaid
CAFHC70992FMedicaid