Healthcare Provider Details

I. General information

NPI: 1417364753
Provider Name (Legal Business Name): KINDER MENDER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 DOBBIN RD
COLUMBIA MD
21045-5804
US

IV. Provider business mailing address

6100 DOBBIN RD
COLUMBIA MD
21045-5804
US

V. Phone/Fax

Practice location:
  • Phone: 443-492-4000
  • Fax:
Mailing address:
  • Phone: 443-492-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KEYVAN RAFEI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 443-492-4000