1285991612 NPI number — MICHAEL J. MCKENNA, MD, PROFESSIONAL CORPORATION

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 1285991612 NPI number — MICHAEL J. MCKENNA, MD, PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL J. MCKENNA, MD, PROFESSIONAL CORPORATION
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:
6
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:
1285991612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2980 N BEVERLY GLEN CIR
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90077-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-474-9809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6070 S FORT APACHE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89148-5657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-307-7700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MCKENNA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
702-307-7700

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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