Basic Information
| Provider Information | |||||||||
| NPI: | 1457437154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY OF ANGELS EMERGENCY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 800817 | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913800817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612950859 | ||||||||
| FaxNumber: | 6612950862 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 W TEMPLE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900265421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | ACOSTA | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2139896160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | A25772 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207PE0004X | A25772 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | A25772 | 01 | CA | PRES. STATE LICENSE# | OTHER | 00A257720 | 05 | CA | MEDICAID | GR0088360 | 05 | CA | MEDICAID | 00A257720L72 | 01 | CA | CAL-OPTIMA ID# | OTHER | P00088664 | 01 | CA | RAILROAD MCARE ID# | OTHER |