1316966542 NPI number — OPTUMCARE MANAGEMENT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316966542 NPI number — OPTUMCARE MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUMCARE MANAGEMENT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316966542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 6400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90504-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-613-5566
Provider Business Mailing Address Fax Number:
310-442-6633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11706 DARLINGTON AVE
Provider Second Line Business Practice Location Address:
APT 202
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90049-5517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-613-5566
Provider Business Practice Location Address Fax Number:
310-442-6633
Provider Enumeration Date:
07/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LIETHEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
952-205-6262

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  A62946 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)