Provider Demographics
NPI:1760119309
Name:WILMINGTON COMMUNITY CLINIC
Entity Type:Organization
Organization Name:WILMINGTON COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-549-5760
Mailing Address - Street 1:1009 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4505
Mailing Address - Country:US
Mailing Address - Phone:310-549-5760
Mailing Address - Fax:
Practice Address - Street 1:1700 GULF AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-1311
Practice Address - Country:US
Practice Address - Phone:310-549-5760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILMINGTON COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center