Provider Demographics
NPI:1437495462
Name:FLORENCE WESTERN MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:FLORENCE WESTERN MEDICAL CLINIC, INC
Other - Org Name:MEDICINA FAMILIAR MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-778-2131
Mailing Address - Street 1:7301 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-2254
Mailing Address - Country:US
Mailing Address - Phone:818-346-2395
Mailing Address - Fax:818-346-4591
Practice Address - Street 1:20440 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91306-3110
Practice Address - Country:US
Practice Address - Phone:818-346-2395
Practice Address - Fax:818-346-4591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52385208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty