Healthcare Provider Details

I. General information

NPI: 1023509643
Provider Name (Legal Business Name): SCOTT WESLEY KENNIFER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S GRAND AVE STE 213
SANTA ANA CA
92705-4434
US

IV. Provider business mailing address

PO BOX 11526
SANTA ANA CA
92711-1526
US

V. Phone/Fax

Practice location:
  • Phone: 714-567-7645
  • Fax: 714-834-7182
Mailing address:
  • Phone: 714-567-7645
  • Fax: 714-834-7182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: