Provider Demographics
NPI:1477550788
Name:ATLANTIC AVENUE MEDICAL CLINIC
Entity Type:Organization
Organization Name:ATLANTIC AVENUE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:IVOR
Authorized Official - Last Name:MOOTOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-562-3414
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-0619
Mailing Address - Country:US
Mailing Address - Phone:323-562-3414
Mailing Address - Fax:323-562-3100
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD STE 333
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3528
Practice Address - Country:US
Practice Address - Phone:323-562-3414
Practice Address - Fax:323-562-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty