Healthcare Provider Details

I. General information

NPI: 1629795521
Provider Name (Legal Business Name): MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 W ROSECRANS AVE STE 22
COMPTON CA
90222-3856
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 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