Basic Information
| Provider Information | |||||||||
| NPI: | 1790999373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES CORP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALTAMED GRAND PLAZA ADHC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 CAMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900401501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237258751 | ||||||||
| FaxNumber: | 3238897843 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W CESAR E CHAVEZ AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900122104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132175300 | ||||||||
| FaxNumber: | 2132175396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | U. | ||||||||
| AuthorizedOfficialTitleorPosition: | AVP,PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3236222429 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QA0600X | 060000676 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 261QF0400X | 060000676 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QA0600X | ADUF0155F | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | ADUF0155F | 05 | CA | MEDICAID |