Basic Information
| Provider Information | |||||||||
| NPI: | 1992430961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CALIFORNIA MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14550 HAYNES ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914111613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184210809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8825 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906602657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184210809 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2022 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | ZARE | ||||||||
| AuthorizedOfficialFirstName: | ELLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8186506700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1932428828 | 05 | CA | MEDICAID |