Provider Demographics
NPI:1962001420
Name:SOUTH CENTRAL MEDICAL CLINIC
Entity Type:Organization
Organization Name:SOUTH CENTRAL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZE OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:QUINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-756-1412
Mailing Address - Street 1:10024 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3112
Mailing Address - Country:US
Mailing Address - Phone:323-756-1412
Mailing Address - Fax:323-756-1413
Practice Address - Street 1:10024 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3112
Practice Address - Country:US
Practice Address - Phone:323-756-1412
Practice Address - Fax:323-756-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty