Healthcare Provider Details

I. General information

NPI: 1023137619
Provider Name (Legal Business Name): KENNETH MIRANDA LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WOODSIDE AVE BLDG W-3
SAN FRANCISCO CA
94127-1221
US

IV. Provider business mailing address

375 WOODSIDE AVE BLDG W-3
SAN FRANCISCO CA
94127-1221
US

V. Phone/Fax

Practice location:
  • Phone: 415-753-4443
  • Fax:
Mailing address:
  • Phone: 415-753-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number12479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: