Provider Demographics
NPI:1700115722
Name:LOS NINOS CHILDREN MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:LOS NINOS CHILDREN MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:626-850-5005
Mailing Address - Street 1:409 E MERCED AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-5061
Mailing Address - Country:US
Mailing Address - Phone:626-931-0901
Mailing Address - Fax:626-931-0905
Practice Address - Street 1:409 E MERCED AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5061
Practice Address - Country:US
Practice Address - Phone:626-931-0901
Practice Address - Fax:626-931-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43966208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A439660Medicaid