Provider Demographics
NPI:1538568068
Name:ANGEL MEDICAL CLINIC
Entity type:Organization
Organization Name:ANGEL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CANCHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-521-8609
Mailing Address - Street 1:8551 LA PALMA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2278
Mailing Address - Country:US
Mailing Address - Phone:714-521-8609
Mailing Address - Fax:
Practice Address - Street 1:8551 LA PALMA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-2278
Practice Address - Country:US
Practice Address - Phone:714-521-8609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB228250Medicare PIN