Provider Demographics
NPI:1750455713
Name:OPTUM CARE NETWORK-INLAND FACULTY MG
Entity Type:Organization
Organization Name:OPTUM CARE NETWORK-INLAND FACULTY MG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IPA-OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALDEMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCATERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-815-4702
Mailing Address - Street 1:952 S MOUNT VERNON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:952 S MOUNT VERNON AVE STE B
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4224
Practice Address - Country:US
Practice Address - Phone:909-433-9111
Practice Address - Fax:909-433-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44334241302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization