Basic Information
Provider Information | |||||||||
NPI: | 1013952159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARESA | ||||||||
FirstName: | KENITH | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 16354 | ||||||||
Address2: |   | ||||||||
City: | BEVERLY HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 902092354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3106599566 | ||||||||
FaxNumber: | 3103606777 | ||||||||
Practice Location | |||||||||
Address1: | 6221 WILSHIRE BLVD | ||||||||
Address2: | SUITE 620 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900485201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3235560090 | ||||||||
FaxNumber: | 3235560094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 06/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | A66233 | CA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 00A662330 | 05 | CA |   | MEDICAID |