Provider Demographics
NPI:1235839002
Name:STEPHENS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:STEPHENS MEDICAL CORPORATION
Other - Org Name:ALTITUDE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-339-9859
Mailing Address - Street 1:21213 HAWTHORNE BLVD STE B
Mailing Address - Street 2:#1101
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-284-2274
Mailing Address - Fax:
Practice Address - Street 1:320 PINE AVE STE 1030
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2366
Practice Address - Country:US
Practice Address - Phone:310-284-2274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health