Provider Demographics
NPI:1780199307
Name:MISSION CITY COMMUNITY NETWORK, INC.
Entity Type:Organization
Organization Name:MISSION CITY COMMUNITY NETWORK, INC.
Other - Org Name:MISSION CITY COMMUNITY NETWORK, INC.-GLENDALE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
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 1:8527 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5824
Mailing Address - Country:US
Mailing Address - Phone:818-895-3100
Mailing Address - Fax:818-893-9464
Practice Address - Street 1:222 W EULALIA ST STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2851
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:818-893-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001476261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550001476OtherSTATE LICENSE