Basic Information
| Provider Information | |||||||||
| NPI: | 1114104858 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALTAMED MEDICAL GROUP EL MONTE FP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 CAMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236222429 | ||||||||
| FaxNumber: | 3238897843 | ||||||||
| Practice Location | |||||||||
| Address1: | 10418 EAST VALLEY BLVD SUITE B | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917313600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264538466 | ||||||||
| FaxNumber: | 6264538465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | U. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3236222429 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTAMED HEALTH SERVICES CORP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QF0050X | HAP70619F | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
| ID | Type | State | Issuer | Description | HAP70619F | 05 | CA | MEDICAID |