MEDICARE: MR. KEITH GLENN KENWORTHY LVN,PHLEBOTOMIST

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	164X00000X	Licensed Vocational Nurse	VN 267760	CA
2	246RP1900X	Phlebotomy Technician	CPT00040181	CA

General Provider Information

NPI Number	:	1871831453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH GLENN KENWORTHY LVN,PHLEBOTOMIST

Provider Business Mailing Address
First Line	:	1764 N ORANGE DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-4307
Country	:	US
Telephone Number	:	323-491-4765
Fax Number	:

Provider Business Practice Location Address
First Line	:	1764 N ORANGE DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-4307
Country	:	US
Telephone Number	:	323-491-4765
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2013
Last Update Date	:	01/16/2013

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