Healthcare Provider Details

I. General information

NPI: 1669604120
Provider Name (Legal Business Name): CLIFFORD KEITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 E ALBERTONI ST #109
CARSON CA
90746-1539
US

IV. Provider business mailing address

637 E ALBERTONI ST #109
CARSON CA
90746-1539
US

V. Phone/Fax

Practice location:
  • Phone: 213-820-1511
  • Fax: 310-626-9754
Mailing address:
  • Phone: 213-820-1511
  • Fax: 310-626-9754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number190600AP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: