Basic Information
| Provider Information | |||||||||
| NPI: | 1316033533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICA MONSIGNOR OSCAR A ROMERO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 S ALVARADO STREET | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900572201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139897700 | ||||||||
| FaxNumber: | 2139897701 | ||||||||
| Practice Location | |||||||||
| Address1: | 2032 MARENGO STREET | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139897700 | ||||||||
| FaxNumber: | 3232214528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROSATTO | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2132012737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 960001398 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC71005F | 05 | CA | MEDICAID |