Provider Demographics
NPI: | 1437372638 |
---|---|
Name: | MABUHAY MEDICAL GROUP |
Entity Type: | Organization |
Organization Name: | MABUHAY MEDICAL GROUP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | GROUP PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | THELMA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LAMORENA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 818-461-5030 |
Mailing Address - Street 1: | 16030 VENTURA BLVD STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | ENCINO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 91436-2754 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 818-461-5030 |
Mailing Address - Fax: | 818-461-5095 |
Practice Address - Street 1: | 16030 VENTURA BLVD STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | ENCINO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91436-2754 |
Practice Address - Country: | US |
Practice Address - Phone: | 818-461-5030 |
Practice Address - Fax: | 818-461-5095 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-04-10 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A29376 | 302R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 302R00000X | Managed Care Organizations | Health Maintenance Organization |