Provider Demographics
NPI:1386927374
Name:CLINICA MEDICA SAN PEDRO OF CALIFORNIA, INC
Entity type:Organization
Organization Name:CLINICA MEDICA SAN PEDRO OF CALIFORNIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-579-0999
Mailing Address - Street 1:11725 GARVEY AVE
Mailing Address - Street 2:STE 5B
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-4534
Mailing Address - Country:US
Mailing Address - Phone:626-579-0999
Mailing Address - Fax:626-579-2999
Practice Address - Street 1:11725 GARVEY AVE
Practice Address - Street 2:STE 5B
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-4534
Practice Address - Country:US
Practice Address - Phone:626-579-0999
Practice Address - Fax:626-579-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty