Healthcare Provider Details

I. General information

NPI: 1508289158
Provider Name (Legal Business Name): HEALTHY FOUNDATIONS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE STE 715
LONG BEACH CA
90813-3408
US

IV. Provider business mailing address

1045 ATLANTIC AVE STE 715
LONG BEACH CA
90813-3408
US

V. Phone/Fax

Practice location:
  • Phone: 562-983-5496
  • Fax: 562-216-8807
Mailing address:
  • Phone: 562-983-5496
  • Fax: 562-216-8807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA45589
License Number StateCA

VIII. Authorized Official

Name: DR. EJIKE C. ONYEADOR
Title or Position: MEDICAL DIRECTOR / OWNER
Credential: M.D.
Phone: 562-983-5496