Provider Demographics
NPI:1194893248
Name:THE LOS ANGELES FREE CLINIC
Entity type:Organization
Organization Name:THE LOS ANGELES FREE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MURIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOUWEZEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-337-1707
Mailing Address - Street 1:8405 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8405 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3401
Practice Address - Country:US
Practice Address - Phone:323-653-8622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QC1500X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70701FMedicaid
CACMM70945FMedicaid
CAEAP00005FMedicaid
CABCP70654FMedicaid
CABCP70701FMedicaid
CAHAP70654FMedicaid
CAFHC70654FMedicaid
CAHAP70701FMedicaid
CAFHC70654FMedicaid
CAHAP70654FMedicaid
CAHAP70701FMedicaid
CA=========AOtherPPP-HMED