=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104399641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KYM FAMILY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 01/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6732 E MORELAND ST
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85257-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-297-3228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6732 E MORELAND ST
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85257-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-297-3228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O.
-----------------------------------------------------
Name | MR. ANTHONY NGEERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-297-3228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171000000X
-----------------------------------------------------
Taxonomy Name | Military Health Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------