Provider Demographics
NPI:1295887024
Name:LA LIBERTAD MEDICAL CLINIC INC
Entity type:Organization
Organization Name:LA LIBERTAD MEDICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:323-585-1056
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:323-585-1056
Mailing Address - Fax:
Practice Address - Street 1:8225 LONG BEACH BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2010
Practice Address - Country:US
Practice Address - Phone:323-585-1056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45384208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101040Medicaid
CA00A453841Medicaid
CAGR0101040Medicaid