Provider Demographics
NPI:1639241888
Name:QUEENSCARE HEALTH CENTERS
Entity Type:Organization
Organization Name:QUEENSCARE HEALTH CENTERS
Other - Org Name:QUEENSCARE HEALTH CENTERS - HOLLYWOOD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELOISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-669-4321
Mailing Address - Street 1:950 S GRAND AVE
Mailing Address - Street 2:2ND FLOOR SOUTH
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4202
Mailing Address - Country:US
Mailing Address - Phone:323-669-4302
Mailing Address - Fax:323-953-6244
Practice Address - Street 1:4618 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1830
Practice Address - Country:US
Practice Address - Phone:323-953-7170
Practice Address - Fax:323-663-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000926261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA551895Medicare Oscar/Certification