Provider Demographics
NPI:1013343078
Name:MAYWOOD HEALTHCARE CLINIC, INC.
Entity Type:Organization
Organization Name:MAYWOOD HEALTHCARE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINONEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:323-861-1510
Mailing Address - Street 1:4205 SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-2835
Mailing Address - Country:US
Mailing Address - Phone:323-560-0118
Mailing Address - Fax:323-560-1302
Practice Address - Street 1:4205 SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-2835
Practice Address - Country:US
Practice Address - Phone:323-560-0118
Practice Address - Fax:323-560-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70433261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA1756OtherPA-C CA LIC #
CAPA19411OtherPA-C CA LIC #
CAA70433OtherMD CA LIC #