Basic Information
| Provider Information | |||||||||
| NPI: | 1982991501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEENKEN | ||||||||
| FirstName: | KANDICE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 CONVOY ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788031 | ||||||||
| FaxNumber: | 8582781708 | ||||||||
| Practice Location | |||||||||
| Address1: | 3750 CONVOY ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788031 | ||||||||
| FaxNumber: | 8582781708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5101019407 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | DO2030 | NV | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 20A15340 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 20A15340 | 01 | CA | CA MEDICAL LICENSE | OTHER | 5101019407 | 01 | MI | MEDICAL LICENSE NUMBER | OTHER | DO2030 | 01 | NV | NV MEDICAL LICENSE | OTHER | 1982991501 | 05 | NV | MEDICAID |