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General NPI Number Information
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NPI Number | 1568649226
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Entity Type | Organization
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Legal Business Name | UPTIMUM MEDICAL GROUP AND IPA INC
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Dates
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Enumeration Date | 01/24/2008
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 2220 W MANCHESTER BLVD
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City | INGLEWOOD
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State | CA
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Zip | 90305-2514
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Country | US
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Telephone | 310-644-8400
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Fax |
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Provider Business Mailing Address
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Address Line | 15342 HAWTHORNE BLVD STE 102
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City | LAWNDALE
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State | CA
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Zip | 90260-2181
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Country | US
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Telephone | 310-644-8400
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Fax | 310-644-8424
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. OLUKEMI ADERONKE WALLACE
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Credential | M.D.
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Telephone | 310-644-8400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A48240
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License Number State | CA
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