| Concierge Medicine/la | |
|
11611 San Vicente Blvd Lobby Level Los Angeles CA 90049-5106 | |
| (310) 826-2555 | |
| (310) 826-2552 |
| Full Name | Concierge Medicine/la |
|---|---|
| Speciality | Clinic/Center |
| Location | 11611 San Vicente Blvd, Los Angeles, California |
| Authorized Official Name and Position | Raphael Darvish (PRESIDENT) |
| Authorized Official Contact | 3108262555 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Concierge Medicine/la 11611 San Vicente Blvd Lobby Level Los Angeles CA 90049-5106 Ph: (310) 826-2555 | Concierge Medicine/la 11611 San Vicente Blvd Lobby Level Los Angeles CA 90049-5106 Ph: (310) 826-2555 |
| NPI Number | 1194058578 |
|---|---|
| Provider Enumeration Date | 09/16/2009 |
| Last Update Date | 09/16/2009 |
| Medicare PECOS PAC ID | 4981740263 |
|---|---|
| Medicare Enrollment ID | O20090930000603 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194058578 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | A92794 (California) | Primary |
| Provider Name | Raphael Darvish |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1245457811 PECOS PAC ID: 8628114980 Enrollment ID: I20090930000488 |
| Provider Name | Melody Fatehi |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1174120943 PECOS PAC ID: 1951714781 Enrollment ID: I20210115000212 |
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