Basic Information
| Provider Information | |||||||||
| NPI: | 1316463763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TARGET CLINIC MEDICAL ASSOCIATES OF SOUTHERN CALIFORNIA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15272 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923360231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2017 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIDOFF | ||||||||
| AuthorizedOfficialFirstName: | RAMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8776080044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.