=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477093128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K. C. MEDIVANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2925 ATHEL DR
-----------------------------------------------------
City | HACIENDA HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91745-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-273-0390
-----------------------------------------------------
Fax | 562-273-0332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1783
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91793-1783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-273-0390
-----------------------------------------------------
Fax | 562-273-0332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KARINA CECILIA CUADRA
-----------------------------------------------------
Credential | N/A
-----------------------------------------------------
Telephone | 562-273-0390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------