MEDICARE: KABO HEALTH LLC

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	111160	AK
2	261QU0200X	Urgent Care Clinic/Center	1048438	AK

General Provider Information

NPI Number	:	1346777505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KABO HEALTH LLC

Provider Business Mailing Address
First Line	:	3521 MOUNTAIN VIEW DR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-1111
Country	:	US
Telephone Number	:	805-766-1049
Fax Number	:	907-868-1105

Provider Business Practice Location Address
First Line	:	3521 MOUNTAIN VIEW DR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-1111
Country	:	US
Telephone Number	:	805-766-1049
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JONATHAN MARK VANRAVENSWAAY
Credential	:	MD
Telephone Number	:	805-766-1049

Provider Enumeration Date	:	05/18/2017
Last Update Date	:	11/10/2023

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Directions to “KABO HEALTH LLC ” Practice Location

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