1417241365 NPI number — KAN-DI-KI LLC

Table of content: (NPI 1417241365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417241365 NPI number — KAN-DI-KI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAN-DI-KI 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:
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:
1417241365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2820 N ONTARIO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURBANK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91504-2015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-549-1880
Provider Business Mailing Address Fax Number:
818-333-7234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3230 E. BROADWAY ROAD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85040-2874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-967-2281
Provider Business Practice Location Address Fax Number:
480-967-0306
Provider Enumeration Date:
06/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VELEZ
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VP
Authorized Official Telephone Number:
800-940-0389

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  03D2024612 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 619775 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03D2024612 . This is a "CLIA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: P01126484 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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