Healthcare Provider Details

I. General information

NPI: 1023094984
Provider Name (Legal Business Name): STEPHEN LOUIS KUCHENBECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD 460 W
SANTA MONICA CA
90404
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD 460 W
SANTA MONICA CA
90404
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-9400
  • Fax: 310-829-6764
Mailing address:
  • Phone: 310-829-9400
  • Fax: 310-829-6764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG30063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: