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General NPI Number Information
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NPI Number | 1215139647
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Entity Type | Individual
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Provider Name | KENNETH BERTRAM ELCONIN M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/05/2007
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Last Update Date | 07/18/2007
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Provider Practice Location Address
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Address Line | 8405 BEVERLY BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90048-3401
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Country | US
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Telephone | 323-653-8622
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Fax | 323-658-6773
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Provider Business Mailing Address
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Address Line | 500 HOMEWOOD RD
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City | LOS ANGELES
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State | CA
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Zip | 90049-1906
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Country | US
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Telephone | 310-472-2983
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Fax | 310-472-0832
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | AFE17621
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License Number State | CA
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