Provider Demographics
NPI:1952716441
Name:QUEENSCARE HEALTH CENTERS
Entity Type:Organization
Organization Name:QUEENSCARE HEALTH CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:B
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-669-4305
Mailing Address - Street 1:950 S GRAND AVE
Mailing Address - Street 2:2ND FLOOR SOUTH
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4202
Mailing Address - Country:US
Mailing Address - Phone:323-669-4326
Mailing Address - Fax:323-953-3658
Practice Address - Street 1:4618 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1977
Practice Address - Country:US
Practice Address - Phone:323-953-7170
Practice Address - Fax:323-669-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-1895OtherMEDICARE FQHC PROVIDER NUMBER
CACMM70660FMedicaid
CAW6997DOtherMEDICARE PROVIDER NUMBER
CAFHC70660FOtherMEDI-CAL FQHC PROVIDER NUMBER