Provider Demographics
NPI:1689073595
Name:GOOD NEIGHBOR CLINIC, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GOOD NEIGHBOR CLINIC, A MEDICAL CORPORATION
Other - Org Name:GOOD NEIGHBOR CLINIC CRENSHAW BOULEVARD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKILLOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-298-1668
Mailing Address - Street 1:4300 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-4902
Mailing Address - Country:US
Mailing Address - Phone:323-298-1668
Mailing Address - Fax:323-298-0458
Practice Address - Street 1:4300 CRENSHAW BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008
Practice Address - Country:US
Practice Address - Phone:323-298-1668
Practice Address - Fax:323-298-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X, 208D00000X, 261Q00000X
CAA31491208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty