Provider Demographics
NPI:1861872566
Name:P.C. MEDICAL CLINIC
Entity type:Organization
Organization Name:P.C. MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-507-8181
Mailing Address - Street 1:631 E COLORADO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-507-8181
Mailing Address - Fax:
Practice Address - Street 1:631 E COLORADO ST
Practice Address - Street 2:SUITE C
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-507-8181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508900887Medicaid
CA1003102856Medicaid