Provider Demographics
NPI:1811166846
Name:LA CLINICA
Entity type:Organization
Organization Name:LA CLINICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-547-6641
Mailing Address - Street 1:1400 W MCFADDEN AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-3438
Mailing Address - Country:US
Mailing Address - Phone:714-546-8200
Mailing Address - Fax:714-546-8755
Practice Address - Street 1:1400 W MCFADDEN AVE STE 4
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-3438
Practice Address - Country:US
Practice Address - Phone:714-546-8200
Practice Address - Fax:714-546-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50959174400000X
CAA33882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A338823Medicaid
CA00A338823Medicaid
CAAD8703856OtherDEA