Provider Demographics
NPI:1558397067
Name:VENICE FAMILY CLINIC
Entity Type:Organization
Organization Name:VENICE FAMILY CLINIC
Other - Org Name:SIMMS/MANN HEALTH & WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITESH
Authorized Official - Middle Name:G
Authorized Official - Last Name:POPAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-664-7901
Mailing Address - Street 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:
Practice Address - Street 1:2509 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1828
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VENICE FAMILY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 261QF0400X
CA960000960261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2424BMedicare ID - Type Unspecified