Provider Demographics
NPI:1639334303
Name:THE CHILDREN'S CLINIC, SERVING CHILDREN AND THEIR FAMILIES
Entity Type:Organization
Organization Name:THE CHILDREN'S CLINIC, SERVING CHILDREN AND THEIR FAMILIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-933-0432
Mailing Address - Street 1:455 E COLUMBIA ST STE 201&6
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1620
Mailing Address - Country:US
Mailing Address - Phone:562-933-0400
Mailing Address - Fax:
Practice Address - Street 1:455 E COLUMBIA ST STE 201&6
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1620
Practice Address - Country:US
Practice Address - Phone:562-933-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000104261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health