Basic Information
| Provider Information | |||||||||
| NPI: | 1639704323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN LUTHER KING JR COMMUNITY MEDICAL GROUP-WILMINGTON AVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12021 WILMINGTON AVE | ||||||||
| Address2: | BUILDING 11, SUITE 1000 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245296755 | ||||||||
| FaxNumber: | 4243388984 | ||||||||
| Practice Location | |||||||||
| Address1: | 12021 WILMINGTON AVE | ||||||||
| Address2: | BUILDING 11, SUITE 1000 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245296755 | ||||||||
| FaxNumber: | 4243388984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2020 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | GALLAGHER | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR & ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4243388902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARTIN LUTHER KING JR COMMUNITY MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 171R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Interpreter | 172V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 207QA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.