Basic Information
| Provider Information | |||||||||
| NPI: | 1790156917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VENICE FAMILY CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LOU COLEN HEALTH & WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 604 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4700 INGLEWOOD BLVD | ||||||||
| Address2: | SUITE # 101 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902305896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
| FaxNumber: | 3106647913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| 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: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QC1500X | 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.