Healthcare Provider Details

I. General information

NPI: 1558453704
Provider Name (Legal Business Name): OPTUMCARE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 REDONDO AVE
LONG BEACH CA
90806-2325
US

IV. Provider business mailing address

600 W 9TH ST SUITE 1409
LOS ANGELES CA
90015-4301
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-7221
  • Fax:
Mailing address:
  • Phone: 213-623-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberPSY 21006
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberPSY 21006
License Number StateCA

VIII. Authorized Official

Name: JOHN G. LIETHEN
Title or Position: SECRETARY
Credential:
Phone: 952-205-6262