Basic Information
| Provider Information | |||||||||
| NPI: | 1487959581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KND DEVELOPMENT 59 LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 4576 KH RANCHO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025967358 | ||||||||
| FaxNumber: | 8335019731 | ||||||||
| Practice Location | |||||||||
| Address1: | 10841 WHITE OAK AVE | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917303811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095816400 | ||||||||
| FaxNumber: | 5025964150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2011 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DVP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 5025967358 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KINDRED HEALTHCARE, INC | ||||||||
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| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | DG736D | 01 | CA | MEDICARE | OTHER |