Healthcare Provider Details

I. General information

NPI: 1306496641
Provider Name (Legal Business Name): MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E COMPTON BLVD
COMPTON CA
90220-2410
US

IV. Provider business mailing address

2215 W ROSECRANS AVE STE 22
COMPTON CA
90222-3856
US

V. Phone/Fax

Practice location:
  • Phone: 424-529-6755
  • Fax: 424-338-8984
Mailing address:
  • Phone: 424-529-6755
  • Fax: 424-338-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 12
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KURT STAUDER
Title or Position: PRESIDENT
Credential:
Phone: 424-529-6755