Provider Demographics
NPI:1457470684
Name:ANGELES COMPREHENSIVE COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:ANGELES COMPREHENSIVE COMMUNITY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAROVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-255-5225
Mailing Address - Street 1:3920 EAGLE ROCK BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3606
Mailing Address - Country:US
Mailing Address - Phone:323-255-5225
Mailing Address - Fax:323-255-5229
Practice Address - Street 1:3920 EAGLE ROCK BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-3606
Practice Address - Country:US
Practice Address - Phone:323-255-5225
Practice Address - Fax:323-255-5229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000708261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOXG182OtherBLUE CROSS
CAZZZ552884OtherBLUE SHIELD
CA1326349960OtherNPI
CA91355OtherHEALTHY FAMILY ENROLLMENT ENTITY
CACB217375OtherMEDICARE PTAN
CA1457470684Medicaid
CAG56432MM2OtherLA CARE
CA1427355981OtherNPI
CA8370190013OtherCIGNA
CA1811043474OtherNPI
CAOO3991OtherHEALTH NET
CA1427003300OtherNPI
CAG56432F11OtherCARE 1ST
CA1326349960OtherNPI