Basic Information
| Provider Information | |||||||||
| NPI: | 1265470868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDEAL HEALTH CARE AND MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6245 DE LONGPRE AVE | ||||||||
| Address2: | 206 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900288253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234622271 | ||||||||
| FaxNumber: | 3237851223 | ||||||||
| Practice Location | |||||||||
| Address1: | 6245 DE LONGPRE AVE | ||||||||
| Address2: | 206 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900288253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234622271 | ||||||||
| FaxNumber: | 3237851223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOAQUIN | ||||||||
| AuthorizedOfficialFirstName: | ARNEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3234622271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0086130 | 05 | CA | MEDICAID | GR0086131 | 05 | CA | MEDICAID |