Provider Demographics
NPI:1811141021
Name:SOUTHLANDS MEDICAL CLINIC
Entity type:Organization
Organization Name:SOUTHLANDS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PADMAJA
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:KANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-913-9551
Mailing Address - Street 1:17171 ROSCOE BLVD
Mailing Address - Street 2:SUITE F215
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8614 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-2913
Practice Address - Country:US
Practice Address - Phone:818-913-9551
Practice Address - Fax:818-647-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 98001208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty