Healthcare Provider Details

I. General information

NPI: 1306622782
Provider Name (Legal Business Name): COLIN BOWMAN KINDLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 OVERLAND AVE
LOS ANGELES CA
90034-6311
US

IV. Provider business mailing address

3745 OVERLAND AVE
LOS ANGELES CA
90034-6311
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-5855
  • Fax:
Mailing address:
  • Phone: 310-392-5855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW126440
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: