Provider Demographics
NPI:1477025278
Name:CONNEXUS FAMILY CLINIC INC
Entity Type:Organization
Organization Name:CONNEXUS FAMILY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODING
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:323-506-9860
Mailing Address - Street 1:1930 E. ANAHEIM STREET
Mailing Address - Street 2:N/A
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3908
Mailing Address - Country:US
Mailing Address - Phone:562-599-2248
Mailing Address - Fax:562-599-8801
Practice Address - Street 1:1930 E. ANAHEIM STREET
Practice Address - Street 2:N/A
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3908
Practice Address - Country:US
Practice Address - Phone:562-599-2248
Practice Address - Fax:562-599-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44667OtherPHYSICIAN LICENSE