| Clinica Western | |
|
875 N Western Ave Los Angeles CA 90029-3759 | |
| (323) 461-0777 | |
| (323) 461-8035 |
| Full Name | Clinica Western |
|---|---|
| Speciality | Clinic/Center |
| Location | 875 N Western Ave, Los Angeles, California |
| Authorized Official Name and Position | Dante Atienza Banta (PRESIDENT) |
| Authorized Official Contact | 3234610777 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Clinica Western 875 N Western Ave Los Angeles CA 90029-3759 Ph: (323) 461-0777 | Clinica Western 875 N Western Ave Los Angeles CA 90029-3759 Ph: (323) 461-0777 |
| NPI Number | 1215100417 |
|---|---|
| Provider Enumeration Date | 04/08/2008 |
| Last Update Date | 08/02/2011 |
| Medicare PECOS PAC ID | 2466523097 |
|---|---|
| Medicare Enrollment ID | O20080625000214 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215100417 | NPI | - | NPPES |
| 00A440791 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | A44079 (California) | Primary |
| Provider Name | Dante A Banta |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1912071085 PECOS PAC ID: 0749351377 Enrollment ID: I20080625000204 |
| Provider Name | Veronica Morales Banta |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1265692925 PECOS PAC ID: 8224340468 Enrollment ID: I20150701000829 |
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