Provider Demographics
NPI:1891123782
Name:FLORENCE WESTERN MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:FLORENCE WESTERN MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-778-2131
Mailing Address - Street 1:15216 VANOWEN ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3601
Mailing Address - Country:US
Mailing Address - Phone:213-840-2356
Mailing Address - Fax:
Practice Address - Street 1:15216 VANOWEN ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3601
Practice Address - Country:US
Practice Address - Phone:213-840-2356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty