| Provider Service Network, Inc | |
|
212 Bailey St Apt 204 Los Angeles CA 90033-2460 | |
| (323) 264-5000 | |
| (323) 264-5003 |
| Full Name | Provider Service Network, Inc |
|---|---|
| Speciality | Family Medicine |
| Location | 212 Bailey St Apt 204, Los Angeles, California |
| Authorized Official Name and Position | Hector Raphael Castillo (CEO) |
| Authorized Official Contact | 3232645000 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Provider Service Network, Inc 212 Bailey St Apt 204 Los Angeles CA 90033-2460 Ph: (323) 264-5000 | Provider Service Network, Inc 212 Bailey St Apt 204 Los Angeles CA 90033-2460 Ph: (323) 264-5000 |
| NPI Number | 1336700012 |
|---|---|
| Provider Enumeration Date | 06/24/2019 |
| Last Update Date | 06/25/2019 |
| Medicare PECOS PAC ID | 7719213578 |
|---|---|
| Medicare Enrollment ID | O20190731003183 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336700012 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Hector Castillo |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1659366136 PECOS PAC ID: 4688645104 Enrollment ID: I20041117001272 |
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