MEDICARE: KINTAUDI & ASSOCIATES MEDICAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WG31192G	OTHER	CA	PPIN
2	G31192	OTHER	CA	MEDICAL LICENSE
3	WPA11462A	OTHER	CA	PPIN

General Provider Information

NPI Number	:	1205874237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINTAUDI & ASSOCIATES MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	1125 CHERRY AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3911
Country	:	US
Telephone Number	:	562-256-1633
Fax Number	:	562-256-1635

Provider Business Practice Location Address
First Line	:	1125 CHERRY AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3911
Country	:	US
Telephone Number	:	562-256-1633
Fax Number	:	562-256-1635

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PRUDENCIA KINTAUDI
Credential	:	M.D.
Telephone Number	:	562-256-1633

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	09/24/2007

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