Healthcare Provider Details

I. General information

NPI: 1104958784
Provider Name (Legal Business Name): KUSH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14015 VAN NESS AVE # 10
GARDENA CA
90249-2937
US

IV. Provider business mailing address

PO BOX 6299
TORRANCE CA
90504-0299
US

V. Phone/Fax

Practice location:
  • Phone: 310-327-7682
  • Fax: 310-327-7765
Mailing address:
  • Phone: 310-327-7682
  • Fax: 310-327-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA45536
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA45536
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA45536
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA45536
License Number StateCA

VIII. Authorized Official

Name: DR. KIANSI BONI
Title or Position: OWNER
Credential: MD
Phone: 310-644-3488