Healthcare Provider Details

I. General information

NPI: 1083791644
Provider Name (Legal Business Name): K. D. MACKNET, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25815 BARTON ROAD SUITE 101
LOMA LINDA CA
92354-3894
US

IV. Provider business mailing address

25815 BARTON ROAD SUITE 101
LOMA LINDA CA
92354-3894
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-0224
  • Fax: 909-796-0225
Mailing address:
  • Phone: 909-796-0224
  • Fax: 909-796-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH D MACKNET JR.
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 909-796-0224