Provider Demographics
NPI:1609251735
Name:T.H.E. CLINIC, INC.
Entity Type:Organization
Organization Name:T.H.E. CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHIEPE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:323-730-1920
Mailing Address - Street 1:3834 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1104
Mailing Address - Country:US
Mailing Address - Phone:323-730-1920
Mailing Address - Fax:213-742-6785
Practice Address - Street 1:3721 S LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-5309
Practice Address - Country:US
Practice Address - Phone:323-730-1920
Practice Address - Fax:213-742-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001020261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9600001020Medicaid