Basic Information
| Provider Information | |||||||||
| NPI: | 1861882946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA LIBERTAD MEDICAL CLINIC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3429 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902552329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232779455 | ||||||||
| FaxNumber: | 5629437518 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 PACIFIC BLVD | ||||||||
| Address2: | SUITE C THRU F | ||||||||
| City: | WALNUT PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902556662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232779455 | ||||||||
| FaxNumber: | 5629437518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2015 | ||||||||
| LastUpdateDate: | 09/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBI | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3235851056 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LA LIBERTAD MEDICAL CLINIC INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.