Basic Information
| Provider Information | |||||||||
| NPI: | 1053580175 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTAMED HEALTH SERVICES CORP | ||||||||
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| OtherOrganizationName: | ALTAMED MEDICAL GROUP-SANTA ANA,17TH STREET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1227 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927063455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145000340 | ||||||||
| FaxNumber: | 7148248886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2008 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | U. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3236222429 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.