Provider Demographics
NPI:1023524980
Name:ST. JOHNS URGENT CARE & MEDICAL CORPORATION
Entity type:Organization
Organization Name:ST. JOHNS URGENT CARE & MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:MANSOUR
Authorized Official - Last Name:ROSTAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-957-9300
Mailing Address - Street 1:1138 NORTH WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1702
Mailing Address - Country:US
Mailing Address - Phone:323-957-9300
Mailing Address - Fax:323-957-9315
Practice Address - Street 1:1138 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1702
Practice Address - Country:US
Practice Address - Phone:323-957-9300
Practice Address - Fax:323-957-9315
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST .JOHN URGENT CARE & MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-14
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50108208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty