Basic Information
| Provider Information | |||||||||
| NPI: | 1700553344 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANAN MEDICAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 E ALTAMONTE DR STE 2200 | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670009 | ||||||||
| FaxNumber: | 4077670022 | ||||||||
| Practice Location | |||||||||
| Address1: | 2705 REBECCA LN STE A | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077670009 | ||||||||
| FaxNumber: | 4077670022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2021 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | KANAN | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4077670009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.