Provider Demographics
NPI:1710102009
Name:MISSION CITY COMMUNITY NETWORK, INC.
Entity Type:Organization
Organization Name:MISSION CITY COMMUNITY NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-895-3100
Mailing Address - Street 1:15206 PARTHENIA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5305
Mailing Address - Country:US
Mailing Address - Phone:818-895-3100
Mailing Address - Fax:818-892-3352
Practice Address - Street 1:4842 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90027-5302
Practice Address - Country:US
Practice Address - Phone:323-644-1110
Practice Address - Fax:323-644-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001162261QC1500X, 261QF0400X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70938FOtherMEDICAL PROVIDER NUMBER
CAHAP70436FMedicaid
CA551067OtherMEDICARE FQHC