Healthcare Provider Details

I. General information

NPI: 1568649226
Provider Name (Legal Business Name): UPTIMUM MEDICAL GROUP AND IPA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W MANCHESTER BLVD
INGLEWOOD CA
90305-2514
US

IV. Provider business mailing address

15342 HAWTHORNE BLVD STE 102
LAWNDALE CA
90260-2181
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-8400
  • Fax:
Mailing address:
  • Phone: 310-644-8400
  • Fax: 310-644-8424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA48240
License Number StateCA

VIII. Authorized Official

Name: DR. OLUKEMI ADERONKE WALLACE
Title or Position: DIRECTOR
Credential: M.D.
Phone: 310-644-8400