Provider Demographics
NPI:1194071225
Name:SAN MANUEL MEDICAL CLINIC INC.
Entity type:Organization
Organization Name:SAN MANUEL MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANJANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-584-8881
Mailing Address - Street 1:7400 PACIFIC BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:WALNUT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5739
Mailing Address - Country:US
Mailing Address - Phone:323-584-8881
Mailing Address - Fax:323-584-8882
Practice Address - Street 1:7400 PACIFIC BLVD
Practice Address - Street 2:STE A
Practice Address - City:WALNUT PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5739
Practice Address - Country:US
Practice Address - Phone:323-584-8881
Practice Address - Fax:323-584-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30390174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty