Provider Demographics
NPI:1265489751
Name:LOS ANGELES CLINICA MEDICA GENERAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:LOS ANGELES CLINICA MEDICA GENERAL MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ACCOUNTS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:213-739-3282
Mailing Address - Street 1:PO BOX 10432
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90213-3432
Mailing Address - Country:US
Mailing Address - Phone:213-637-2530
Mailing Address - Fax:231-384-3373
Practice Address - Street 1:2208 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4002
Practice Address - Country:US
Practice Address - Phone:213-384-3434
Practice Address - Fax:213-386-2039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076110Medicaid
W14020Medicare PIN