=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780026328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPTIMUM CARE MEDICAL GROUP &IPA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2013
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15342 HAWTHORNE BLVD STE 102
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-644-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2220 W MANCHESTER BLVD
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90305-2514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-644-8400
-----------------------------------------------------
Fax | 310-644-8424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. OLUKEMI A WALLACE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-644-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | A48240
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 23055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 23055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 23055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number | 23055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 23055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 23055
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------