Healthcare Provider Details

I. General information

NPI: 1780098525
Provider Name (Legal Business Name): OPTUMCARE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19191 S VERMONT AVE SUITE 200
TORRANCE CA
90502-1018
US

IV. Provider business mailing address

P.O. BOX 6400
TORRANCE CA
90504-6400
US

V. Phone/Fax

Practice location:
  • Phone: 310-354-4221
  • Fax:
Mailing address:
  • Phone: 310-354-4221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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