Provider Demographics
NPI:1720171242
Name:UNIVERSITY MUSLIM MEDICAL ASSOCIATION INC
Entity type:Organization
Organization Name:UNIVERSITY MUSLIM MEDICAL ASSOCIATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-313-5588
Mailing Address - Street 1:711 W FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044
Mailing Address - Country:US
Mailing Address - Phone:323-789-5610
Mailing Address - Fax:323-789-5616
Practice Address - Street 1:711 W FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044
Practice Address - Country:US
Practice Address - Phone:323-789-5610
Practice Address - Fax:323-789-5616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH701898OtherPUBLIC PRIVATE PARTNERSHI
CA051099OtherMEDICARE PROVIDER NUMBER
CABCP70908FMedicaid
CAFHC70908FMedicaid
CAEAP70908FMedicaid
CAHAP70908FMedicaid