Provider Demographics
NPI:1376929828
Name:ST ANTOINE DE PADOUE HEALTH CLINIC CORP.
Entity Type:Organization
Organization Name:ST ANTOINE DE PADOUE HEALTH CLINIC CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BERGERETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAINT-VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:562-977-5715
Mailing Address - Street 1:127 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-4344
Mailing Address - Country:US
Mailing Address - Phone:562-977-5715
Mailing Address - Fax:562-977-5715
Practice Address - Street 1:127 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-4344
Practice Address - Country:US
Practice Address - Phone:562-324-6901
Practice Address - Fax:562-977-5715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABU21412090261Q00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center