Healthcare Provider Details

I. General information

NPI: 1497106843
Provider Name (Legal Business Name): KECK MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SAN PABLO ST SUITE 322
LOS ANGELES CA
90033-5320
US

IV. Provider business mailing address

1510 SAN PABLO ST SUITE 322
LOS ANGELES CA
90033-5320
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-7419
  • Fax:
Mailing address:
  • Phone: 323-442-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberA109957
License Number StateCA

VIII. Authorized Official

Name: STEVEN CARLSON
Title or Position: CLINICAL INSTRUCTOR
Credential: MD
Phone: 805-458-0306