Provider Demographics
NPI:1720077852
Name:FIRST INTEGRATED CARE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FIRST INTEGRATED CARE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELNORA
Authorized Official - Middle Name:T
Authorized Official - Last Name:TABILA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:562-492-6698
Mailing Address - Street 1:1339 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-3116
Mailing Address - Country:US
Mailing Address - Phone:562-492-6698
Mailing Address - Fax:562-492-9553
Practice Address - Street 1:1339 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-3116
Practice Address - Country:US
Practice Address - Phone:562-492-6698
Practice Address - Fax:562-492-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A385440Medicaid
CAW13447Medicare PIN
CAW13447AMedicare PIN