Provider Demographics
NPI:1952461774
Name:LOS REYES CLIINICA MEDICA, INC
Entity Type:Organization
Organization Name:LOS REYES CLIINICA MEDICA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-584-9644
Mailing Address - Street 1:7934 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6804
Mailing Address - Country:US
Mailing Address - Phone:323-584-9644
Mailing Address - Fax:323-583-0012
Practice Address - Street 1:7934 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:WALNUT PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-6804
Practice Address - Country:US
Practice Address - Phone:323-583-9644
Practice Address - Fax:323-583-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty