Provider Demographics
NPI:1154386209
Name:UNIVERSAL PRIMARY CARE
Entity type:Organization
Organization Name:UNIVERSAL PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLADYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-454-4481
Mailing Address - Street 1:1560 E CHEVY CHASE DR
Mailing Address - Street 2:SUITE 245
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-246-5900
Mailing Address - Fax:818-956-7633
Practice Address - Street 1:1560 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 245
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-246-5900
Practice Address - Fax:818-956-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059753Medicaid
CAGR0059753Medicaid