Provider Demographics
NPI:1710160049
Name:CLINICA DEL PUEBLO
Entity Type:Organization
Organization Name:CLINICA DEL PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EARLA
Authorized Official - Middle Name:E
Authorized Official - Last Name:QUISIDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-845-2399
Mailing Address - Street 1:10200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:CA
Mailing Address - Zip Code:93241-1700
Mailing Address - Country:US
Mailing Address - Phone:661-845-2399
Mailing Address - Fax:661-845-1791
Practice Address - Street 1:10200 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMONT
Practice Address - State:CA
Practice Address - Zip Code:93241-1700
Practice Address - Country:US
Practice Address - Phone:661-845-2399
Practice Address - Fax:661-845-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48100208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A481000Medicaid