Healthcare Provider Details

I. General information

NPI: 1033627591
Provider Name (Legal Business Name): KKMMCB MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 SOUTH 300 WEST SUITE 200
SANDY UT
84070
US

IV. Provider business mailing address

1338 S FOOTHILL DR #331
SALT LAKE CITY UT
84108-2321
US

V. Phone/Fax

Practice location:
  • Phone: 385-254-0279
  • Fax:
Mailing address:
  • Phone: 385-254-0279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LIZETTE MORIN
Title or Position: MDMS NPI COMPLIANCE OFFICER
Credential:
Phone: 210-598-2800