Healthcare Provider Details

I. General information

NPI: 1285452771
Provider Name (Legal Business Name): UPTIMUM MEDICAL GROUP AND IPA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W MANCHESTER BLVD
INGLEWOOD CA
90305-2514
US

IV. Provider business mailing address

2220 W MANCHESTER BLVD
INGLEWOOD CA
90305-2514
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: OLUKEMI A WALLACE
Title or Position: DIRECTOR
Credential: MD
Phone: 310-644-8400