Provider Demographics
NPI:1871837344
Name:VENICE FAMILY CLINIC
Entity type:Organization
Organization Name:VENICE FAMILY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLACKBIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-664-7941
Mailing Address - Street 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:310-664-7711
Practice Address - Street 1:604 ROSE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-664-7735
Practice Address - Fax:310-396-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy