Organization
SOUTHERN CALIFORNIA SPECIALTY CARE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MOSTAFA ADAM DARVISH (EXECUTIVE DIRECTOR)
(714) 893-4541
Entity
Organization
Contact information
Practice address
845 N LARK ELLEN AVE, WEST COVINA, CA 91791
(626) 339-5451
(626) 967-3809
Mailing address
845 N LARK ELLEN AVE, WEST COVINA, CA 91791-1069
(626) 339-5451
(626) 967-3809
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
954494848
TRICARE/CHAMPUS
CA
05
—
HSP32028F
—
CA
01
—
ZZZB1900Z
BLUE CROSS
CA
Enumeration date
08/20/2009
Last updated
07/23/2018
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