Basic Information
Provider Information | |||||||||
NPI: | 1407061930 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALTAMED HEALTH SERVICES CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALTAMED GOLDEN AGE ADHC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2040 CAMFIELD AVE | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900401501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3237258751 | ||||||||
FaxNumber: | 3238897850 | ||||||||
Practice Location | |||||||||
Address1: | 3820 MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | LYNWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 90262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3106320415 | ||||||||
FaxNumber: | 3106392734 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 08/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | U. | ||||||||
AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
AuthorizedOfficialTelephone: | 3236222429 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | 060000588 | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 261QF0400X | 060000588 | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X |   | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QA0600X | AUDF0030G | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
ID | Type | State | Issuer | Description | ADUF0030G | 05 | CA |   | MEDICAID |