=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942358221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDEL THIRLBENNY PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 04/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 E ARTESIA BLVD
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90805-1476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-423-3383
-----------------------------------------------------
Fax | 877-469-3649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 OCEANGATE SUITE 100
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90802-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-499-6191
-----------------------------------------------------
Fax | 877-469-3649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA 16098
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------