MEDICARE: KINGSTON HEALTH GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	261QU0200X	Urgent Care Clinic/Center
3	2084P0800X	Psychiatry Physician
4	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1760200356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGSTON HEALTH GROUP

Provider Business Mailing Address
First Line	:	955 CARRILLO DR STE 900
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5472
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	955 CARRILLO DR STE 900
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5472
Country	:	US
Telephone Number	:	424-502-0336
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL JACOB GHODS
Credential	:
Telephone Number	:	424-258-0124

Provider Enumeration Date	:	10/01/2024
Last Update Date	:	11/25/2025

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Directions to “KINGSTON HEALTH GROUP ” Practice Location

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