Provider Demographics
NPI:1427234590
Name:MISSION CITY COMMUNITY NETWORK,INC
Entity type:Organization
Organization Name:MISSION CITY COMMUNITY NETWORK,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:818-895-3100
Mailing Address - Street 1:15206 PARTHENIA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5305
Mailing Address - Country:US
Mailing Address - Phone:818-895-3100
Mailing Address - Fax:818-892-3352
Practice Address - Street 1:10200 SEPULVEDA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-3321
Practice Address - Country:US
Practice Address - Phone:818-830-1441
Practice Address - Fax:818-221-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23299261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70436FMedicaid
CAFHC70436FMedicaid
CAHAP70436FMedicaid
CAW11698OtherGROUP ID