Provider Demographics
NPI:1851849863
Name:PALMDALE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:PALMDALE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:V
Authorized Official - Last Name:GORELIKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-947-5600
Mailing Address - Street 1:540 W PALMDALE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4232
Mailing Address - Country:US
Mailing Address - Phone:661-947-5600
Mailing Address - Fax:661-947-5900
Practice Address - Street 1:540 W PALMDALE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4232
Practice Address - Country:US
Practice Address - Phone:661-947-5600
Practice Address - Fax:661-947-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA102339OtherMEDICAL LIC