Provider Demographics
NPI:1467653873
Name:HARBOR COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:HARBOR COMMUNITY CLINIC INC
Other - Org Name:BEACON STREET HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMRA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-547-8241
Mailing Address - Street 1:593 W. 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3738
Mailing Address - Country:US
Mailing Address - Phone:310-547-0202
Mailing Address - Fax:310-547-8048
Practice Address - Street 1:731 S. BEACON ST.
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2521
Practice Address - Country:US
Practice Address - Phone:310-732-5887
Practice Address - Fax:310-547-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000067261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN