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General NPI Number Information
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NPI Number | 1588907554
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Entity Type | Organization
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Legal Business Name | KMCI SERVICE MANAGEMENT, LLC
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Dates
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Enumeration Date | 03/28/2013
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Last Update Date | 09/05/2013
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Provider Practice Location Address
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Address Line | 3131 MCKINNEY AVE SUITE 600
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City | DALLAS
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State | TX
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Zip | 75204-7426
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Country | US
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Telephone | 972-505-1584
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Fax | 682-422-3020
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Provider Business Mailing Address
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Address Line | 3131 MCKINNEY AVE SUITE 600
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City | DALLAS
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State | TX
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Zip | 75204-7426
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Country | US
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Telephone | 972-505-1584
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Fax | 682-422-3020
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AVIAN DESHIVER KIDD
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Credential | MD
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Telephone | 972-505-1584
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | M1829
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License Number State | TX
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