Provider Demographics
NPI:1750470134
Name:LA CLINIC OF MEDICINE GENETICS AND PREVENTIVE CARE
Entity type:Organization
Organization Name:LA CLINIC OF MEDICINE GENETICS AND PREVENTIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVANSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-655-2799
Mailing Address - Street 1:647 N HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2224
Mailing Address - Country:US
Mailing Address - Phone:323-655-2799
Mailing Address - Fax:323-655-0556
Practice Address - Street 1:369 N FAIRFAX AVE STE 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2175
Practice Address - Country:US
Practice Address - Phone:323-655-2799
Practice Address - Fax:323-655-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70174207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A701740Medicaid
CA00A701740Medicaid
CAI11375Medicare UPIN