Provider Demographics
NPI:1902192362
Name:SAN MANUEL MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:SAN MANUEL MEDICAL CLINIC, INC
Other - Org Name:PHILLIP RUIZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:M,D
Authorized Official - Phone:323-584-8881
Mailing Address - Street 1:7400 PACIFIC BLVD
Mailing Address - Street 2:SUITE# A-B
Mailing Address - City:WALNUT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5739
Mailing Address - Country:US
Mailing Address - Phone:323-584-8881
Mailing Address - Fax:323-584-8882
Practice Address - Street 1:7400 PACIFIC BLVD
Practice Address - Street 2:A
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5739
Practice Address - Country:US
Practice Address - Phone:323-584-8881
Practice Address - Fax:323-584-8882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULTI-CULTURAL MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-23
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44599207Q00000X
CAA30390207Q00000X
CAA41503208000000X
CAPA15560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15560OtherMULTI-SPECIALTY GROUP-PHYSICIAN ASSISTANT
CAA44599OtherMULTI-SPECIALTY GROUP- FAMILY MEDICINE