Provider Demographics
NPI:1376711440
Name:VENICE CULVER MARINA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:VENICE CULVER MARINA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEHRANI
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING MANAGER
Authorized Official - Phone:310-672-9000
Mailing Address - Street 1:PO BOX 24706
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024
Mailing Address - Country:US
Mailing Address - Phone:310-391-5241
Mailing Address - Fax:310-397-4324
Practice Address - Street 1:12212 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066
Practice Address - Country:US
Practice Address - Phone:310-391-5241
Practice Address - Fax:310-397-4324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VENICE CULVER MARINA MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-12
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
CAA32561261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13797Medicare PIN
CAW13797Medicare UPIN