Provider Demographics
NPI:1114726148
Name:VENICE FAMILY CLINIC - VENICE, CA
Entity type:Organization
Organization Name:VENICE FAMILY CLINIC - VENICE, CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKBIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-664-7941
Mailing Address - Street 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:622 ROSE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-664-7941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VENICE FAMILY CLINIC - VENICE, CA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-11
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)