1417091992 NPI number — KMD MEDICAL GROUP, INC.

Table of content: AVA MARIE LITTON PT (NPI 1790913069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417091992 NPI number — KMD MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KMD MEDICAL GROUP, 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:
1417091992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 KRISTEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 FROST ST
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-2771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-637-4800
Provider Business Practice Location Address Fax Number:
858-637-4801
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOSOY
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-637-4800

Provider Taxonomy Codes

  • Taxonomy code: 204F00000X , with the licence number:  A60375 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: A60375 , 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: CE226Y . This is a "MEDICARE PTAN (BALBOA NEPHROLOGY MEDICAL GROUP)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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