Basic Information
| Provider Information | |||||||||
| NPI: | 1235663758 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF LOS ANGELES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EAST SAN GABRIEL VALLEY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302900 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302900 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2017 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | QUENTIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AMBULATORY NETWORK, CEO | ||||||||
| AuthorizedOfficialTelephone: | 2132889000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF LOS ANGELES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.