Provider Demographics
NPI:1588078166
Name:EDGEMONT MEDICAL CLINIC
Entity type:Organization
Organization Name:EDGEMONT MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMORANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-504-7265
Mailing Address - Street 1:4864 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2634
Mailing Address - Country:US
Mailing Address - Phone:818-504-7265
Mailing Address - Fax:818-504-1623
Practice Address - Street 1:4864 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2634
Practice Address - Country:US
Practice Address - Phone:818-504-7265
Practice Address - Fax:818-504-1623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10630208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043482060OtherNPI
CA1881986826OtherNPI 1881986826