Provider Demographics
NPI:1790901361
Name:MC MEDICAL CLINIC
Entity Type:Organization
Organization Name:MC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELCHOR
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLANTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-929-4894
Mailing Address - Street 1:12100 IMPERIAL HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-3081
Mailing Address - Country:US
Mailing Address - Phone:562-929-4894
Mailing Address - Fax:562-929-6555
Practice Address - Street 1:12100 IMPERIAL HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3081
Practice Address - Country:US
Practice Address - Phone:562-929-4894
Practice Address - Fax:562-929-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37955261QP2300X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Not Answered302R00000XManaged Care OrganizationsHealth Maintenance Organization
Not Answered305R00000XManaged Care OrganizationsPreferred Provider Organization
Not Answered305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN96343OtherBLUE CROSS PCP
CA00A379550Medicare ID - Type Unspecified
CAN96343OtherBLUE CROSS PCP