Healthcare Provider Details

I. General information

NPI: 1215848569
Provider Name (Legal Business Name): KHKMFT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W 200 N
ALPINE UT
84004-1364
US

IV. Provider business mailing address

102 W 200 N
ALPINE UT
84004-1364
US

V. Phone/Fax

Practice location:
  • Phone: 714-624-3784
  • Fax:
Mailing address:
  • Phone: 714-624-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN KELLY
Title or Position: OWNER
Credential:
Phone: 714-624-3784