1144226861 NPI number — MEK KENNEDY, 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 1144226861 NPI number — MEK KENNEDY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEK KENNEDY, 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:
KENNEDY CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1144226861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1506 S GLENDALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91205-3316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
181-824-7620
Provider Business Mailing Address Fax Number:
181-824-7712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
619 N FAIRFAX AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90036-1714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
132-365-1004
Provider Business Practice Location Address Fax Number:
132-365-1375
Provider Enumeration Date:
06/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PEDRAJA
Authorized Official First Name:
FERNAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
181-824-7620

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  970000040 , 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)

  • Identifier: 05D0556903 . This is a "CLIA ID NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZT05977G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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