Provider Demographics
NPI:1104960558
Name:LA VASCULAR ACCESS CTR MEDICAL GRP
Entity type:Organization
Organization Name:LA VASCULAR ACCESS CTR MEDICAL GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-674-9300
Mailing Address - Street 1:323 N PRAIRIE AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4502
Mailing Address - Country:US
Mailing Address - Phone:310-674-9300
Mailing Address - Fax:310-674-9301
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-674-9300
Practice Address - Fax:310-674-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0105550OtherMEDI-CAL - GROUP
CAW21161OtherMEDICARE - GROUP
CA=========OtherTAX ID