Basic Information
| Provider Information | |||||||||
| NPI: | 1003369661 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KANAN MEDICAL, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ALTAMONTEMD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 460 E ALTAMONTE DR | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670009 | ||||||||
| FaxNumber: | 4077670022 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 E ALTAMONTE DR | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670009 | ||||||||
| FaxNumber: | 4077670022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2016 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KANAN | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4077670009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 023512400 | 05 | FL | MEDICAID |