Provider Demographics
NPI:1962475244
Name:SOUTH VALLEY INTERNAL MEDICINE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOUTH VALLEY INTERNAL MEDICINE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTIVE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLALBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-397-4910
Mailing Address - Street 1:540 S MARENGO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3130
Mailing Address - Country:US
Mailing Address - Phone:626-397-4910
Mailing Address - Fax:626-397-4911
Practice Address - Street 1:18356 CLARK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3502
Practice Address - Country:US
Practice Address - Phone:626-397-4910
Practice Address - Fax:626-397-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67014174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA607841115OtherSS#
CA00A670140Medicaid
CAA67014Medicare ID - Type UnspecifiedLICEBSE #
CA00A670140Medicaid