Basic Information
| Provider Information | |||||||||
| NPI: | 1700291119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 ZONAL AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232236146 | ||||||||
| FaxNumber: | 3232236399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 ZONAL AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232236146 | ||||||||
| FaxNumber: | 3232236399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 06/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC/PROGRAM ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3232236146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ADMINISTRATOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.