MEDICARE: KC MEDICAL ENTERPRISE PLLC

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	207R00000X	Internal Medicine Physician	7430003-1205	UT

General Provider Information

NPI Number	:	1396037206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KC MEDICAL ENTERPRISE PLLC

Provider Business Mailing Address
First Line	:	415 SOUTH MEDICAL DR STE C201
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-992-3130
Fax Number	:	801-992-3146

Provider Business Practice Location Address
First Line	:	415 SOUTH MEDICAL DR STE C201
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-298-2332
Fax Number	:	801-298-5018

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CYNTHIA CANGA-SIAO
Credential	:	MD
Telephone Number	:	801-992-3130

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	12/21/2012

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