Provider Demographics
NPI:1326133687
Name:THE VIDAL WOMANS MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:THE VIDAL WOMANS MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:G
Authorized Official - Last Name:VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-755-5500
Mailing Address - Street 1:1601 N SEPULVEDA BLVD # 400
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5111
Mailing Address - Country:US
Mailing Address - Phone:323-755-5500
Mailing Address - Fax:323-755-5522
Practice Address - Street 1:11502 S VERMONT AVE STE B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-6522
Practice Address - Country:US
Practice Address - Phone:323-755-5500
Practice Address - Fax:323-755-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A780690Medicaid