Provider Demographics
NPI:1760671077
Name:UNIVERSAL MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:UNIVERSAL MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GHOLAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOSSEINIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-323-9999
Mailing Address - Street 1:18701 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4045
Mailing Address - Country:US
Mailing Address - Phone:310-323-9999
Mailing Address - Fax:
Practice Address - Street 1:18701 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4045
Practice Address - Country:US
Practice Address - Phone:310-323-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A724850Medicaid
CA00A521780Medicaid
CA00A521780Medicaid
CAA52178Medicare UPIN