Basic Information
| Provider Information | |||||||||
| NPI: | 1629795521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 W ROSECRANS AVE STE 22 | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902223856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245296755 | ||||||||
| FaxNumber: | 4243388984 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 W ROSECRANS AVE STE 22 | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902223856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245296755 | ||||||||
| FaxNumber: | 4243388984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2022 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | STAUDER | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4243388760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.