Provider Demographics
NPI:1548740939
Name:MISSION CITY COMMUNITY NETWORK INC
Entity Type:Organization
Organization Name:MISSION CITY COMMUNITY NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-895-3100
Mailing Address - Street 1:8527 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5824
Mailing Address - Country:US
Mailing Address - Phone:818-895-3100
Mailing Address - Fax:818-893-9464
Practice Address - Street 1:5300 SANTA MONICA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:818-893-9464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION CITY COMMUNITY NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-15
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001476261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherMEDICARE
CA=========Medicaid