Provider Demographics
NPI:1356015580
Name:SERRA COMMUNITY MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:SERRA COMMUNITY MEDICAL CLINIC INC
Other - Org Name:SERRA COMMUNITY MEDICAL CLINIC- VAN NUYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-504-4701
Mailing Address - Street 1:9375 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-1418
Mailing Address - Country:US
Mailing Address - Phone:818-504-4504
Mailing Address - Fax:818-504-4637
Practice Address - Street 1:6850 SEPULVEDA BLVD STE 209
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4453
Practice Address - Country:US
Practice Address - Phone:818-504-4504
Practice Address - Fax:818-504-4637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty