Healthcare Provider Details

I. General information

NPI: 1407597453
Provider Name (Legal Business Name): MACKENZIE KINGSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 VICENTE ST
SAN FRANCISCO CA
94116-2923
US

IV. Provider business mailing address

1801 VICENTE ST
SAN FRANCISCO CA
94116-2923
US

V. Phone/Fax

Practice location:
  • Phone: 415-681-3211
  • Fax:
Mailing address:
  • Phone: 415-681-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number1407597453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: