Provider Demographics
NPI:1639704323
Name:MARTIN LUTHER KING JR COMMUNITY MEDICAL GROUP WILMINGTON AVE
Entity Type:Organization
Organization Name:MARTIN LUTHER KING JR COMMUNITY MEDICAL GROUP WILMINGTON AVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-529-6755
Mailing Address - Street 1:2215 W ROSECRANS AVE STE 22
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90222-3856
Mailing Address - Country:US
Mailing Address - Phone:424-338-8760
Mailing Address - Fax:424-338-8984
Practice Address - Street 1:12021 WILMINGTON AVE
Practice Address - Street 2:BUILDING 11, SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:424-529-6755
Practice Address - Fax:424-338-8984
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN LUTHER KING JR COMMUNITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-03
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty