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General NPI Number Information
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NPI Number | 1679066476
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Entity Type | Organization
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Legal Business Name | FREEDOM PARK MEDICAL SERVICES A MEDICAL CORPORATION
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Dates
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Enumeration Date | 06/07/2018
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Last Update Date | 10/28/2019
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Provider Practice Location Address
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Address Line | 1081 N CHINA LAKE BLVD
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City | RIDGECREST
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State | CA
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Zip | 93555-3130
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Country | US
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Telephone | 469-401-2386
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 99103
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City | LAS VEGAS
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State | NV
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Zip | 89193-9085
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Country | US
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Telephone | 954-838-2371
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Fax |
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Authorized Official
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Title or Position | VP PROVIDER ENROLLMENT
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Name | KATHLEEN KONDAS
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Credential |
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Telephone | 973-251-1132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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