Provider Demographics
NPI:1972560563
Name:SMENSA MEDICAL GROUP, PC
Entity type:Organization
Organization Name:SMENSA MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRANFORD
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-673-6581
Mailing Address - Street 1:PO BOX 1698
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90308-1698
Mailing Address - Country:US
Mailing Address - Phone:310-673-6581
Mailing Address - Fax:310-419-4493
Practice Address - Street 1:625 E HARDY ST
Practice Address - Street 2:SUITE 222
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4106
Practice Address - Country:US
Practice Address - Phone:310-673-6581
Practice Address - Fax:310-419-4493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32142261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19613Medicare ID - Type Unspecified
CAA34821Medicare UPIN