Basic Information
Provider Information | |||||||||
NPI: | 1932428828 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN CALIFORNIA MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14550 HAYNES ST FL 3 | ||||||||
Address2: |   | ||||||||
City: | VAN NUYS | ||||||||
State: | CA | ||||||||
PostalCode: | 914114116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8186506700 | ||||||||
FaxNumber: | 5626997066 | ||||||||
Practice Location | |||||||||
Address1: | 8825 WHITTIER BLVD | ||||||||
Address2: |   | ||||||||
City: | PICO RIVERA | ||||||||
State: | CA | ||||||||
PostalCode: | 906602600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626993333 | ||||||||
FaxNumber: | 5626997009 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2010 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUSHERI | ||||||||
AuthorizedOfficialFirstName: | SHEILA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6266993333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QD0000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QE0800X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QF0050X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QH0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM2500X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QC1500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.