Provider Demographics
NPI:1538701206
Name:MAIN MEDICAL HEALTH CLINIC INC
Entity Type:Organization
Organization Name:MAIN MEDICAL HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:LIEZL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-634-7127
Mailing Address - Street 1:23517 MAIN ST STE 108
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-5239
Mailing Address - Country:US
Mailing Address - Phone:310-518-6246
Mailing Address - Fax:
Practice Address - Street 1:23517 MAIN ST STE 108
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-5239
Practice Address - Country:US
Practice Address - Phone:310-518-6246
Practice Address - Fax:310-518-6247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-14
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty