MEDICARE: ALTAMED HEALTH SERVICES CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1104252378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTAMED HEALTH SERVICES CORP

Provider Business Mailing Address
First Line	:	2040 CAMFIELD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90040-1501
Country	:	US
Telephone Number	:	323-622-2429
Fax Number	:	323-889-7399

Provider Business Practice Location Address
First Line	:	1424 CRUSADO LN
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1512
Country	:	US
Telephone Number	:	323-226-0623
Fax Number	:	323-889-7399

Authorized Official
Title or Position	:	AVP,PATIENT FINANCIAL SERVICES
Name	:	ROBERT U. YOUNG
Credential	:	M.D.
Telephone Number	:	323-622-2429

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/19/2013

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