Provider Demographics
NPI:1659307981
Name:CLINICA SANTA CLARA
Entity Type:Organization
Organization Name:CLINICA SANTA CLARA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KEUSAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-771-1713
Mailing Address - Street 1:7643 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:CA
Mailing Address - Zip Code:90201
Mailing Address - Country:US
Mailing Address - Phone:323-771-1713
Mailing Address - Fax:323-562-1302
Practice Address - Street 1:7643 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:CA
Practice Address - Zip Code:90201
Practice Address - Country:US
Practice Address - Phone:323-771-1713
Practice Address - Fax:323-562-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0060940Medicaid
CAGR0060940Medicaid
CAW13136Medicare ID - Type UnspecifiedPROVIDER #