Healthcare Provider Details

I. General information

NPI: 1285818096
Provider Name (Legal Business Name): JOHN K MCKISSOCK MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 LOMITA BLVD 150
TORRANCE CA
90505-4801
US

IV. Provider business mailing address

3440 LOMITA BLVD 150
TORRANCE CA
90505-4801
US

V. Phone/Fax

Practice location:
  • Phone: 310-257-9425
  • Fax: 310-530-2146
Mailing address:
  • Phone: 310-257-9425
  • Fax: 310-530-2146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG84015
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN K MCKISSOCK
Title or Position: PROPRIETOR
Credential: M.D.
Phone: 310-257-9425