Provider Demographics
NPI:1194071753
Name:POLICLINICA FAMILIAR SAN JUDAS INC
Entity type:Organization
Organization Name:POLICLINICA FAMILIAR SAN JUDAS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLADIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:FUNES
Authorized Official - Suffix:
Authorized Official - Credentials:FAMILY NURSE PRACTIT
Authorized Official - Phone:323-725-1144
Mailing Address - Street 1:6007 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4401
Mailing Address - Country:US
Mailing Address - Phone:323-725-1144
Mailing Address - Fax:323-725-1153
Practice Address - Street 1:6007 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:EAST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4401
Practice Address - Country:US
Practice Address - Phone:323-725-1144
Practice Address - Fax:323-725-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMDMedicare UPIN
CANPMedicare UPIN