Provider Demographics
NPI:1932425899
Name:SANTA TERESITA MEDICAL CLINIC GROUP INC
Entity Type:Organization
Organization Name:SANTA TERESITA MEDICAL CLINIC GROUP INC
Other - Org Name:SANTA TERESITA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:323-222-5550
Mailing Address - Street 1:2929 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-2602
Mailing Address - Country:US
Mailing Address - Phone:323-222-5550
Mailing Address - Fax:323-222-5552
Practice Address - Street 1:2929 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2602
Practice Address - Country:US
Practice Address - Phone:323-222-5550
Practice Address - Fax:323-222-5552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA61248BMedicare UPIN