Provider Demographics
NPI:1386020303
Name:ALTAMED
Entity Type:Organization
Organization Name:ALTAMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CASTULO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:877-462-2582
Mailing Address - Street 1:2040 CAMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-1502
Mailing Address - Country:US
Mailing Address - Phone:323-725-8751
Mailing Address - Fax:
Practice Address - Street 1:535 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3013
Practice Address - Country:US
Practice Address - Phone:626-214-1484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA847492302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization