Basic Information
| Provider Information | |||||||||
| NPI: | 1003095464 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALTAMED MEDICAL GROUP EAPC PROP 99 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CITADEL DR | ||||||||
| Address2: | STE 490 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237258751 | ||||||||
| FaxNumber: | 3238897843 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CITADEL DR | ||||||||
| Address2: | STE 490 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237258751 | ||||||||
| FaxNumber: | 3238897399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ESPARZA | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 3237258751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTAMED HEALTH SERVICES CORP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | EAP11568F | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | EAP11568F | 01 | CA | EAPC PROGRAM | OTHER |