Basic Information
Provider Information | |||||||||
NPI: | 1992964746 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VENICE FAMILY CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | IRMA COLEN HEALTH CENTER FPACT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 604 ROSE AVE | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | CA | ||||||||
PostalCode: | 902912767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103928636 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4700 INGLEWOOD BLVD STE 102 | ||||||||
Address2: |   | ||||||||
City: | CULVER CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 902305896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103928636 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2008 | ||||||||
LastUpdateDate: | 09/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORER | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: | BENSON | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3106647901 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VENICE FAMILY CLINIC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW. MPH | ||||||||
NPICertificationDate: | 09/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 960001387 | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.