Provider Demographics
NPI:1992430961
Name:SOUTHERN CALIFORNIA MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-650-6700
Mailing Address - Street 1:14550 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1613
Mailing Address - Country:US
Mailing Address - Phone:818-421-0809
Mailing Address - Fax:
Practice Address - Street 1:8825 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2657
Practice Address - Country:US
Practice Address - Phone:818-421-0809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932428828Medicaid