Basic Information
| Provider Information | |||||||||
| NPI: | 1154406718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIENLE | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | S | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 HIGUERA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934012917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055434043 | ||||||||
| FaxNumber: | 8055434427 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 HIGUERA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934012917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055434043 | ||||||||
| FaxNumber: | 8055434427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A8454 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7588391 | 01 | CIGNA HEALTH CARE PIN | OTHER |