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General NPI Number Information
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NPI Number | 1669344149
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Entity Type | Organization
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Legal Business Name | MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION
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Dates
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Enumeration Date | 09/23/2025
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Last Update Date | 09/23/2025
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Provider Practice Location Address
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Address Line | 1122 W WASHINGTON BLVD STE 305
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City | LOS ANGELES
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State | CA
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Zip | 90015-3349
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Country | US
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Telephone | 424-529-6755
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Fax | 424-338-8984
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Provider Business Mailing Address
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Address Line | 1122 W WASHINGTON BLVD STE 305
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City | LOS ANGELES
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State | CA
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Zip | 90015-3349
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Country | US
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Telephone | 424-529-6755
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Fax | 424-338-8984
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Authorized Official
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Title or Position | COO
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Name | JEFFREY STOUT
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Credential |
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Telephone | 424-338-8711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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