Provider Demographics
NPI:1821532508
Name:CENTRO MEDICO DEL CARMEN
Entity Type:Organization
Organization Name:CENTRO MEDICO DEL CARMEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:ROSA
Authorized Official - Last Name:ASCENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:CLECMA
Authorized Official - Phone:213-219-8054
Mailing Address - Street 1:13373 PERRIS BLVD
Mailing Address - Street 2:SUITE C202A
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5441
Mailing Address - Country:US
Mailing Address - Phone:951-242-8155
Mailing Address - Fax:951-242-8311
Practice Address - Street 1:13373 PERRIS BLVD
Practice Address - Street 2:SUITE C202A
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5441
Practice Address - Country:US
Practice Address - Phone:951-242-8155
Practice Address - Fax:951-242-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52193208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19646OtherMEDICARE ID:
CA00521930Medicaid
CA00521930Medicaid