Basic Information
| Provider Information | |||||||||
| NPI: | 1275591802 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC REGENTS UCLA FAMILY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018713 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1920 COLORADO AVE | ||||||||
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| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904043414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103194700 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | DOWLING | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3108258234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZP1939Z | 05 | CA | MEDICAID | GR005503G | 05 | CA | MEDICAID |