Provider Demographics
NPI:1790240125
Name:CLINICA LA VICTORIA AMC
Entity Type:Organization
Organization Name:CLINICA LA VICTORIA AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:661-835-2600
Mailing Address - Street 1:2303 S UNION AVE
Mailing Address - Street 2:SUITE E9
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93307
Mailing Address - Country:US
Mailing Address - Phone:661-835-2600
Mailing Address - Fax:661-835-2603
Practice Address - Street 1:2303 S UNION AVE
Practice Address - Street 2:SUITE E9
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307
Practice Address - Country:US
Practice Address - Phone:661-835-2600
Practice Address - Fax:661-835-2603
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINICA LA VICTORIA AMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184777922OtherNPI TO MAIN CORP