Provider Demographics
NPI:1730819079
Name:SNL MEDICAL CENTER A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SNL MEDICAL CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-616-4484
Mailing Address - Street 1:7400 VAN NUYS BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-1972
Mailing Address - Country:US
Mailing Address - Phone:818-616-6484
Mailing Address - Fax:818-616-4494
Practice Address - Street 1:7400 VAN NUYS BLVD STE 111
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1972
Practice Address - Country:US
Practice Address - Phone:818-616-4484
Practice Address - Fax:818-616-4494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG68903OtherMEDICAL BOARD