Provider Demographics
NPI:1760409791
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:818-892-4651
Practice Address - Street 1:15206 PARTHENIA ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5305
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:818-892-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000465261QA0005X, 261QC1500X, 261QF0400X
CAFHC70436F261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70436FOtherMEDICAL PROVIDER NUMBER
CAFHC70436FOtherMEDICAL PROVIDER NUMBER
CAHAP70436FOtherMEDICAL PROVIDER NUMBER
CA551023OtherMEDICARE PTAN
CAW11698Medicare PIN