Provider Demographics
NPI:1164243218
Name:CARE LEAGUE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:CARE LEAGUE MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-341-2681
Mailing Address - Street 1:18653 VENTURA BLVD # 125
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18653 VENTURA BLVD # 125
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4103
Practice Address - Country:US
Practice Address - Phone:213-341-2681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty