Healthcare Provider Details

I. General information

NPI: 1639704323
Provider Name (Legal Business Name): MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 05/14/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE BUILDING 11, SUITE 1000
LOS ANGELES CA
90059
US

IV. Provider business mailing address

2215 W ROSECRANS AVE STE 22
COMPTON CA
90222-3856
US

V. Phone/Fax

Practice location:
  • Phone: 424-529-6755
  • Fax: 424-338-8984
Mailing address:
  • Phone: 424-338-8760
  • Fax: 424-338-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KURT STAUDER
Title or Position: PRESIDENT
Credential:
Phone: 424-529-6755