Provider Demographics
NPI:1467654590
Name:LOYOLA MEDICAL CENTER A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LOYOLA MEDICAL CENTER A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:VENEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-564-6464
Mailing Address - Street 1:4225 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6217
Mailing Address - Country:US
Mailing Address - Phone:323-564-6464
Mailing Address - Fax:323-564-8578
Practice Address - Street 1:4225 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6217
Practice Address - Country:US
Practice Address - Phone:323-564-6464
Practice Address - Fax:323-564-8578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A393700Medicaid
CA00A393700Medicaid
CAW11581Medicare ID - Type Unspecified