Provider Demographics
NPI:1639604895
Name:FAMILY HEALTH CLINIC INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:V
Authorized Official - Last Name:MUNGCAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-480-0748
Mailing Address - Street 1:133 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-5904
Mailing Address - Country:US
Mailing Address - Phone:213-480-0748
Mailing Address - Fax:213-480-1661
Practice Address - Street 1:133 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-5904
Practice Address - Country:US
Practice Address - Phone:213-480-0748
Practice Address - Fax:213-480-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42598261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A425980Medicaid
CA00A425980Medicaid