Provider Demographics
NPI:1770774366
Name:SUPERIOR MULTI SPECIALTY MEDICAL CLINIC INC.
Entity type:Organization
Organization Name:SUPERIOR MULTI SPECIALTY MEDICAL CLINIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:EHSAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-390-9551
Mailing Address - Street 1:11600 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4014
Mailing Address - Country:US
Mailing Address - Phone:310-390-9551
Mailing Address - Fax:310-390-9296
Practice Address - Street 1:11600 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4014
Practice Address - Country:US
Practice Address - Phone:310-390-9551
Practice Address - Fax:310-390-9296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50372261QM2500X, 261QE0002X, 261QM1300X, 261QP3300X
CAA50312261QU0200X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770774366Medicaid
CA1770774366Medicaid