Basic Information
| Provider Information | |||||||||
| NPI: | 1952067738 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VENICE FAMILY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORER | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | BENSON | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3106647901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VENICE FAMILY CLINIC | ||||||||
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| AuthorizedOfficialCredential: | MSW. MPH | ||||||||
| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.