Basic Information
| Provider Information | |||||||||
| NPI: | 1801030804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAC USC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18417 JEFFREY AVE | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907036150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624020727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 ZONAL AVE | ||||||||
| Address2: | IRD BUILDING,INTERNAL MEDICINE DEPARTMENT | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900890121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232267556 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | BEN -ARI | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3232267556 | ||||||||
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| 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 | 261QP2300X | A105552 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 282N00000X | A105552 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.