Basic Information
| Provider Information | |||||||||
| NPI: | 1104174333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEDREN INTEGRATED CARE SYSTEM, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232330425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2012 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFITH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3232330425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.