Provider Demographics
NPI:1922582592
Name:CLINICA MEDICA LATINA, INC
Entity Type:Organization
Organization Name:CLINICA MEDICA LATINA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:MOISES
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-601-6618
Mailing Address - Street 1:24805 ALESSANDRO BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-6101
Mailing Address - Country:US
Mailing Address - Phone:951-601-6618
Mailing Address - Fax:951-247-6218
Practice Address - Street 1:24805 ALESSANDRO BLVD STE 8
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-6101
Practice Address - Country:US
Practice Address - Phone:951-601-6618
Practice Address - Fax:951-247-6218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA70384OtherPROFESSIONAL LICENSE
.Other.