Provider Demographics
NPI:1841500253
Name:EASTSIDE DIABETES CARE MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:EASTSIDE DIABETES CARE MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALTAGRACIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-726-0370
Mailing Address - Street 1:5836 E BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-2824
Mailing Address - Country:US
Mailing Address - Phone:323-726-0370
Mailing Address - Fax:323-726-0239
Practice Address - Street 1:5836 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-2824
Practice Address - Country:US
Practice Address - Phone:323-726-0370
Practice Address - Fax:323-726-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33652261QH0100X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A336520Medicaid
1972600880OtherNPI
A33652Medicare UPIN
CAC35421Medicare UPIN
CA00A336520Medicaid
C35421Medicare PIN