1750364345 NPI number — KAN-DI-KI LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750364345 NPI number — KAN-DI-KI LLC

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 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:

1750364345

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

03/18/2025

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

930 RIDGEBROOK RD FL 3

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SPARKS

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21152-9481

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

800-786-8015

Provider Business Mailing Address Fax Number:

410-472-1754

Provider First Line Business Practice Location Address:

12612 RAYMER ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

NORTH HOLLYWOOD

Provider Business Practice Location Address State Name:

CA

Provider Business Practice Location Address Postal Code:

91605-4307

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

818-549-1880

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

11/28/2005

Authorized Official Last Name:

CUOMO

Authorized Official First Name:

BRIAN

Authorized Official Middle Name:

C

Authorized Official Title or Position:

AUTHORIZED OFFICIAL/CFO

Authorized Official Telephone Number:

7-868-0158

• Taxonomy code: 291U00000X , with the licence number:  205582 , registered in the state of CA ; 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: "N" .
• Taxonomy code: 335V00000X , with the licence number: 043518 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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• Identifier: 2443518 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
• Identifier: 414224201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: ZZZ31268Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
• Identifier: 05D0679751 . This is a "CLIA NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
• Identifier: LAB79751F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
• Identifier: ZZZ59811Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
• Identifier: 500621162 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
• Identifier: 1750364345 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: XR059811F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".