Provider Demographics
NPI:1508289158
Name:HEALTHY FOUNDATIONS MEDICAL GROUP
Entity Type:Organization
Organization Name:HEALTHY FOUNDATIONS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EJIKE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ONYEADOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-983-5496
Mailing Address - Street 1:1045 ATLANTIC AVE
Mailing Address - Street 2:STE 715
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3408
Mailing Address - Country:US
Mailing Address - Phone:562-983-5496
Mailing Address - Fax:562-216-8807
Practice Address - Street 1:1045 ATLANTIC AVE
Practice Address - Street 2:STE 715
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3408
Practice Address - Country:US
Practice Address - Phone:562-983-5496
Practice Address - Fax:562-216-8807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45589208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45589Medicaid