Organization
ALISO MEDICAL CLINIC, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CHRISTINE BARNES-KEITH (ADMINISTRATOR)
(323) 268-8391
Entity
Organization
Contact information
Practice address
1625 E 4TH ST, LOS ANGELES, CA 90033-4201
(323) 268-8391
(323) 268-8014
Mailing address
1625 E 4TH ST, LOS ANGELES, CA 90033-4201
(323) 268-8391
(323) 268-8014
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
A28934
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00A289340
—
CA
01
—
11513273
CAQH ID
CA
05
—
GR0067720
—
CA
01
—
ZZZ74805Z
BLUE SHIELD GRP PIN
CA
Enumeration date
02/26/2007
Last updated
08/22/2020
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