Healthcare Provider Details

I. General information

NPI: 1669127379
Provider Name (Legal Business Name): K&MT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E INDIAN SCHOOL RD APT 2119
PHOENIX AZ
85012-1886
US

IV. Provider business mailing address

1701 E MEADOWBROOK AVE APT 346
PHOENIX AZ
85016-5113
US

V. Phone/Fax

Practice location:
  • Phone: 480-241-2197
  • Fax:
Mailing address:
  • Phone: 480-241-2197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: AMANDA WILSON
Title or Position: OWNER
Credential:
Phone: 480-241-2197