MEDICARE: ULTIMED MEDICAL CLINIC, INC.

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	207R00000X	Internal Medicine Physician	A53451	CA

General Provider Information

NPI Number	:	1649228982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTIMED MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	5300 SANTA MONICA BLVD
Second Line	:	SUITE 304
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1131
Country	:	US
Telephone Number	:	323-993-0700
Fax Number	:	323-993-0734

Provider Business Practice Location Address
First Line	:	5300 SANTA MONICA BLVD
Second Line	:	SUITE 304
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1131
Country	:	US
Telephone Number	:	323-993-0700
Fax Number	:	323-993-0734

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MANOLITO SOSA BUENDIA
Credential	:	M.D.
Telephone Number	:	661-799-9585

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	08/22/2020

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