Healthcare Provider Details

I. General information

NPI: 1184878340
Provider Name (Legal Business Name): KEITH O KIELMEYER MD PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5536 E LANE AVE
FRESNO CA
93727-5336
US

IV. Provider business mailing address

5536 E LANE AVE
FRESNO CA
93727-5336
US

V. Phone/Fax

Practice location:
  • Phone: 559-970-3411
  • Fax:
Mailing address:
  • Phone: 559-970-3411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC35402
License Number StateCA

VIII. Authorized Official

Name: DR. KEITH O KIELMEYER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-970-3411