Basic Information
| Provider Information | |||||||||
| NPI: | 1245716190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISKIN | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 CENTRAL AVE STE C | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925302740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 27450 YNEZ RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925914649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516955144 | ||||||||
| FaxNumber: | 9516959345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2018 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 14318 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 296676 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | CA364305 | 01 | CA | MEDICARE | OTHER | CA364306 | 01 | CA | MEDICARE | OTHER |