Provider Demographics
NPI:1942548342
Name:SAN MIGUEL COMMUNITY CLINIC
Entity type:Organization
Organization Name:SAN MIGUEL COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KJ
Authorized Official - Middle Name:
Authorized Official - Last Name:LAESSIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-742-0255
Mailing Address - Street 1:825 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3002
Mailing Address - Country:US
Mailing Address - Phone:909-622-9988
Mailing Address - Fax:909-622-3452
Practice Address - Street 1:825 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3002
Practice Address - Country:US
Practice Address - Phone:909-622-9988
Practice Address - Fax:909-622-3452
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SAN MIGUEL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0016851Medicaid
CAGR0016851Medicaid