Provider Demographics
NPI:1215263827
Name:CLINICA DEL SOCORRO MEDICAL GROUP,INC.
Entity type:Organization
Organization Name:CLINICA DEL SOCORRO MEDICAL GROUP,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-233-9686
Mailing Address - Street 1:1061 E VERNON AVE
Mailing Address - Street 2:SUITE 'F'
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-3772
Mailing Address - Country:US
Mailing Address - Phone:323-233-9686
Mailing Address - Fax:323-233-0595
Practice Address - Street 1:1061 E VERNON AVE
Practice Address - Street 2:SUITE 'F'
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-3772
Practice Address - Country:US
Practice Address - Phone:323-233-9686
Practice Address - Fax:323-233-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39153207Q00000X
CAA20149208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE08447Medicare UPIN
CAA22039Medicare UPIN