Provider Demographics
NPI:1407500374
Name:MISSION CITY COMMUNITY NETWORK INC
Entity Type:Organization
Organization Name:MISSION CITY COMMUNITY NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-895-3100
Mailing Address - Street 1:MISSION CITY COMMUNITY NETWORK INC.
Mailing Address - Street 2:3660 WILSHIRE BLVD, SUITE 102,
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2763
Mailing Address - Country:US
Mailing Address - Phone:818-895-3100
Mailing Address - Fax:818-830-0811
Practice Address - Street 1:MISSION CITY COMMUNITY NETWORK, INC
Practice Address - Street 2:3660 WILSHIRE BLVD, SUITE 102,
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2763
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:818-830-0811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954226189Medicaid