# SOUTHERN CALIFORNIA SPECIALTY CARE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1164654315
- **Authorized official:** MR. MOSTAFA ADAM DARVISH (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (714) 893-4541

## Contact information

- **Practice address:** 845 N LARK ELLEN AVE, WEST COVINA, CA 91791
- **Practice address phone:** (626) 339-5451
- **Practice address fax:** (626) 967-3809
- **Mailing address:** 845 N LARK ELLEN AVE, WEST COVINA, CA 91791-1069
- **Mailing address phone:** (626) 339-5451
- **Mailing address fax:** (626) 967-3809

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 08/20/2009
- **Last updated:** 07/23/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 954494848 | TRICARE/CHAMPUS | CA |
| 05 | — | HSP32028F | — | CA |
| 01 | — | ZZZB1900Z | BLUE CROSS | CA |