Healthcare Provider Details

I. General information

NPI: 1780026328
Provider Name (Legal Business Name): UPTIMUM CARE MEDICAL GROUP &IPA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15342 HAWTHORNE BLVD STE 102
LAWNDALE CA
90260-2152
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:
Mailing address:
  • Phone: 310-644-8400
  • Fax: 310-644-8424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberA48240
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number23055
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number23055
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number23055
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number23055
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number23055
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number23055
License Number StateCA

VIII. Authorized Official

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