Healthcare Provider Details

I. General information

NPI: 1831489855
Provider Name (Legal Business Name): KAILI JI SHUMILAK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18406 ROSCOE BLVD
NORTHRIDGE CA
91325-4107
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 818-993-4054
  • Fax:
Mailing address:
  • Phone: 619-906-4623
  • Fax: 619-906-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12796
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: