Healthcare Provider Details

I. General information

NPI: 1588907554
Provider Name (Legal Business Name): KMCI SERVICE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 MCKINNEY AVE SUITE 600
DALLAS TX
75204-7426
US

IV. Provider business mailing address

3131 MCKINNEY AVE SUITE 600
DALLAS TX
75204-7426
US

V. Phone/Fax

Practice location:
  • Phone: 972-505-1584
  • Fax: 682-422-3020
Mailing address:
  • Phone: 972-505-1584
  • Fax: 682-422-3020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM1829
License Number StateTX

VIII. Authorized Official

Name: DR. AVIAN DESHIVER KIDD
Title or Position: PRESIDENT
Credential: MD
Phone: 972-505-1584