Provider Demographics
NPI:1851735351
Name:GOOD SHEPHARD MEDICAL CLINIC
Entity Type:Organization
Organization Name:GOOD SHEPHARD MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:NERLANDE
Authorized Official - Last Name:LAMOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-635-7123
Mailing Address - Street 1:201 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-1425
Mailing Address - Country:US
Mailing Address - Phone:310-635-7123
Mailing Address - Fax:310-635-0535
Practice Address - Street 1:661 W 1RST STREEET # G
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:714-665-9891
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANJ HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QM0850X
CA960001116261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health