Provider Demographics
NPI:1245655240
Name:LA LIBERTAD MEDICAL CLINIC INC
Entity type:Organization
Organization Name:LA LIBERTAD MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHAMBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-277-9455
Mailing Address - Street 1:PO BOX 3429
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2329
Mailing Address - Country:US
Mailing Address - Phone:323-277-9455
Mailing Address - Fax:323-277-9450
Practice Address - Street 1:7900 PACIFIC BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-6662
Practice Address - Country:US
Practice Address - Phone:323-277-9455
Practice Address - Fax:323-277-9450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA LIBERTAD MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18996Medicare PIN