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General NPI Number Information
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NPI Number | 1396486197
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Entity Type | Organization
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Legal Business Name | KMK MEDICAL SERVICE, P.C.
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 14742 NEWPORT AVE STE 209
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City | TUSTIN
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State | CA
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Zip | 92780-6177
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Country | US
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Telephone | 949-395-5835
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Fax |
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Provider Business Mailing Address
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Address Line | 3334 E COAST HWY # 713
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City | CORONA DEL MAR
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State | CA
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Zip | 92625-2328
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KEVIN KHOUIE
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Credential | MD
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Telephone | 949-395-5835
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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