Provider Demographics
NPI:1669344149
Name:MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION
Entity type:Organization
Organization Name:MARTIN LUTHER KING JR COMMUNITY MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-338-8711
Mailing Address - Street 1:1122 W WASHINGTON BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3349
Mailing Address - Country:US
Mailing Address - Phone:424-529-6755
Mailing Address - Fax:424-338-8984
Practice Address - Street 1:1122 W WASHINGTON BLVD STE 305
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3349
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 FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty