Provider Demographics
NPI:1730299157
Name:MORNINGSIDE PRIMARY CARE
Entity type:Organization
Organization Name:MORNINGSIDE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEMMON
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-750-9715
Mailing Address - Street 1:617 W MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-5718
Mailing Address - Country:US
Mailing Address - Phone:323-750-9715
Mailing Address - Fax:323-750-1532
Practice Address - Street 1:617 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-5718
Practice Address - Country:US
Practice Address - Phone:323-750-9715
Practice Address - Fax:323-750-1532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORNINGSIDE PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-30
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059701Medicaid