Healthcare Provider Details

I. General information

NPI: 1104174333
Provider Name (Legal Business Name): KEDREN INTEGRATED CARE SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD BUILDING A
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

4211 AVALON BLVD BUILDING A
LOS ANGELES CA
90011-5622
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-0425
  • Fax:
Mailing address:
  • Phone: 323-233-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN H GRIFFITH
Title or Position: PRESIDENT/CEO
Credential: PH.D.
Phone: 323-233-0425