Provider Demographics
NPI:1780816934
Name:SOUTHERN CALIFORNIA SPECIALTY CARE, LLC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA SPECIALTY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSTAFA
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:DARVISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-893-4541
Mailing Address - Street 1:1901 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2334
Mailing Address - Country:US
Mailing Address - Phone:714-564-7800
Mailing Address - Fax:714-564-7814
Practice Address - Street 1:1901 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706
Practice Address - Country:US
Practice Address - Phone:714-564-7800
Practice Address - Fax:714-564-7814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZD3003ZOtherBLUE CROSS
CAHSP32028FMedicaid
CAHSP32028FMedicaid