Healthcare Provider Details

I. General information

NPI: 1417241365
Provider Name (Legal Business Name): KAN-DI-KI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 E. BROADWAY ROAD SUITE 100
PHOENIX AZ
85040-2874
US

IV. Provider business mailing address

2820 N ONTARIO ST
BURBANK CA
91504-2015
US

V. Phone/Fax

Practice location:
  • Phone: 480-967-2281
  • Fax: 480-967-0306
Mailing address:
  • Phone: 818-549-1880
  • Fax: 818-333-7234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D2024612
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID VELEZ
Title or Position: EXECUTIVE VP
Credential:
Phone: 800-940-0389