Provider Demographics
NPI:1366484909
Name:SAN GABRIEL VALLEY MEDICAL CENTER
Entity Type:Organization
Organization Name:SAN GABRIEL VALLEY MEDICAL CENTER
Other - Org Name:SAN GABRIEL VALLEY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HOUSHANG
Authorized Official - Middle Name:
Authorized Official - Last Name:ABD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-570-0612
Mailing Address - Street 1:438 W LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1216
Mailing Address - Country:US
Mailing Address - Phone:626-570-6640
Mailing Address - Fax:626-457-7153
Practice Address - Street 1:438 W LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1216
Practice Address - Country:US
Practice Address - Phone:626-570-6640
Practice Address - Fax:626-457-7153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
CAPHY489323336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094550OtherPK