Provider Demographics
NPI:1942309497
Name:LINCOLN HEIGHTS FAMILY AND INDUSTRIAL MEDICAL CLINIC
Entity Type:Organization
Organization Name:LINCOLN HEIGHTS FAMILY AND INDUSTRIAL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:HONG
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-225-8038
Mailing Address - Street 1:2409 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-2218
Mailing Address - Country:US
Mailing Address - Phone:323-225-8038
Mailing Address - Fax:323-225-2106
Practice Address - Street 1:2409 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2218
Practice Address - Country:US
Practice Address - Phone:323-225-8038
Practice Address - Fax:323-225-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53847207Q00000X, 208000000X
CAA35695207VX0000X
CAA33894208D00000X
CAPA 13853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056500Medicaid
CAGR0056500Medicaid
CAA27288Medicare UPIN