Basic Information
| Provider Information | |||||||||
| NPI: | 1104476480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIC 2 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3724 N 3RD ST # 201 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023449850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6313 SCHIRRA CT STE A1 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933132191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803314222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2019 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | SONNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4808747012 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QI0500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Infusion Therapy |
No ID Information.