Provider Demographics
NPI:1497889810
Name:NOGALES MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:NOGALES MEDICAL CLINIC, INC
Other - Org Name:NOGALES MEDICAL CLINIC, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-931-6618
Mailing Address - Street 1:1840 N HACIENDA BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1143
Mailing Address - Country:US
Mailing Address - Phone:626-931-6618
Mailing Address - Fax:626-931-6610
Practice Address - Street 1:1840 N HACIENDA BLVD STE 10
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-1143
Practice Address - Country:US
Practice Address - Phone:626-931-6618
Practice Address - Fax:626-931-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CAA70384261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A703840Medicaid
CAA70384AMedicare ID - Type UnspecifiedMEDI-CARE PROVIDER #