Provider Demographics
NPI:1326317595
Name:CLOVER MEDICAL CORPORATION INC
Entity Type:Organization
Organization Name:CLOVER MEDICAL CORPORATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-762-8702
Mailing Address - Street 1:12134 VICTORY BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3205
Mailing Address - Country:US
Mailing Address - Phone:818-762-8702
Mailing Address - Fax:818-761-2583
Practice Address - Street 1:12134 VICTORY BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3205
Practice Address - Country:US
Practice Address - Phone:818-762-8702
Practice Address - Fax:818-761-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-17
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty