Provider Demographics
NPI:1821130113
Name:ISC SAN PEDRO BLASSER CLINIC
Entity Type:Organization
Organization Name:ISC SAN PEDRO BLASSER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-732-7500
Mailing Address - Street 1:1001 S SEASIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-7333
Mailing Address - Country:US
Mailing Address - Phone:310-732-7500
Mailing Address - Fax:310-732-7519
Practice Address - Street 1:1001 S SEASIDE AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-7333
Practice Address - Country:US
Practice Address - Phone:310-732-7500
Practice Address - Fax:310-732-7519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient