Basic Information
Provider Information | |||||||||
NPI: | 1558397067 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VENICE FAMILY CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SIMMS/MANN HEALTH & WELLNESS CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 604 ROSE AVE | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | CA | ||||||||
PostalCode: | 902912767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103928636 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2509 PICO BLVD | ||||||||
Address2: |   | ||||||||
City: | SANTA MONICA | ||||||||
State: | CA | ||||||||
PostalCode: | 904051828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103928636 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 02/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORER | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: | BENSON | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3106647901 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VENICE FAMILY CLINIC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW,MPH | ||||||||
NPICertificationDate: | 02/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 261QC1500X | 960000960 | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.