Healthcare Provider Details

I. General information

NPI: 1649088857
Provider Name (Legal Business Name): KUOKOA DME PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 LINDA VISTA DR STE B
SAN MARCOS CA
92078-3825
US

IV. Provider business mailing address

1205 LINDA VISTA DR STE B
SAN MARCOS CA
92078-3825
US

V. Phone/Fax

Practice location:
  • Phone: 760-304-8166
  • Fax:
Mailing address:
  • Phone: 760-304-8166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SPENCER SMITH
Title or Position: PRESIDENT
Credential: MD
Phone: 808-652-3621