Provider Demographics
NPI:1821635079
Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Other - Org Name:TARGET CLINIC MEDICAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-608-0044
Mailing Address - Street 1:393 E WALNUT ST GPEU 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-1070
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:3471 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-1218
Practice Address - Country:US
Practice Address - Phone:877-608-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-06
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization