Healthcare Provider Details

I. General information

NPI: 1356557060
Provider Name (Legal Business Name): KAKKIS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 E PACIFIC COAST HWY STE 140
LONG BEACH CA
90803-4213
US

IV. Provider business mailing address

6700 E PACIFIC COAST HWY STE 140
LONG BEACH CA
90803-4213
US

V. Phone/Fax

Practice location:
  • Phone: 562-799-1176
  • Fax: 562-493-2823
Mailing address:
  • Phone: 562-799-1176
  • Fax: 562-493-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG48142
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberG48227
License Number StateCA

VIII. Authorized Official

Name: DR. JOYCE A KAKKIS
Title or Position: PRESIDENT
Credential: MD
Phone: 562-799-1176