Provider Demographics
NPI:1205100468
Name:VENICE FAMILY CLINIC
Entity type:Organization
Organization Name:VENICE FAMILY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-664-7667
Mailing Address - Street 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-3311
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000960261QC1500X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health