Provider Demographics
NPI:1265686117
Name:YORK GLEN MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:YORK GLEN MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-254-2811
Mailing Address - Street 1:5417 YORK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2401
Mailing Address - Country:US
Mailing Address - Phone:323-254-2811
Mailing Address - Fax:323-254-1788
Practice Address - Street 1:5417 YORK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-2401
Practice Address - Country:US
Practice Address - Phone:323-254-2811
Practice Address - Fax:323-254-1788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU897Medicare PIN