| Active Mobile Medical Group, Inc. | |
|
3450 Wilshire Blvd Ste 1200 Los Angeles CA 90010-2214 | |
| (213) 465-2643 | |
| (213) 232-4944 |
| Full Name | Active Mobile Medical Group, Inc. |
|---|---|
| Speciality | Family Medicine |
| Location | 3450 Wilshire Blvd Ste 1200, Los Angeles, California |
| Authorized Official Name and Position | Joanna Balasico (VICE PRESIDENT) |
| Authorized Official Contact | 2134652643 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Active Mobile Medical Group, Inc. 3325 Wilshire Blvd Ste 208 Los Angeles CA 90010-1733 Ph: (213) 465-2643 | Active Mobile Medical Group, Inc. 3450 Wilshire Blvd Ste 1200 Los Angeles CA 90010-2214 Ph: (213) 465-2643 |
| NPI Number | 1184370199 |
|---|---|
| Provider Enumeration Date | 02/28/2022 |
| Last Update Date | 03/18/2022 |
| Medicare PECOS PAC ID | 8527445766 |
|---|---|
| Medicare Enrollment ID | O20220510000700 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1184370199 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
| Provider Name | Richard Park |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1174718134 PECOS PAC ID: 5698964906 Enrollment ID: I20110118000516 |
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