Provider Demographics
NPI:1801127162
Name:FREE CLINIC OF SIMI VALLEY
Entity type:Organization
Organization Name:FREE CLINIC OF SIMI VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:805-522-3733
Mailing Address - Street 1:2060 TAPO ST.
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3417
Mailing Address - Country:US
Mailing Address - Phone:805-522-3733
Mailing Address - Fax:805-522-9576
Practice Address - Street 1:2060 TAPO ST.
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-3417
Practice Address - Country:US
Practice Address - Phone:805-522-3733
Practice Address - Fax:805-522-9576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADUN#197915861OtherFEDERAL