Basic Information
| Provider Information | |||||||||
| NPI: | 1124234505 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900224506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238882887 | ||||||||
| FaxNumber: | 3238882889 | ||||||||
| Practice Location | |||||||||
| Address1: | 6210 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900224506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238882887 | ||||||||
| FaxNumber: | 3238882889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANTY | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | AVP LTC, ADHC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2132175300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CA | MEDICAID |