1952474066 NPI number — KINETIC CONDITIONING INSTITUTE, INC

Table of content: (NPI 1952474066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952474066 NPI number — KINETIC CONDITIONING INSTITUTE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINETIC CONDITIONING INSTITUTE, INC
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:
1952474066
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4105 OCEAN VIEW BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MONTROSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91020-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-957-1980
Provider Business Mailing Address Fax Number:
818-957-1905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4105 OCEAN VIEW BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MONTROSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91020-1520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-957-1980
Provider Business Practice Location Address Fax Number:
818-957-1905
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ADOLPHI
Authorized Official First Name:
LEIZL-ANN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-957-1980

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT20048 , 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)