Basic Information
| Provider Information | |||||||||
| NPI: | 1871514687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8260 LONGLEAF DR, | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
| FaxNumber: | 9512732318 | ||||||||
| Practice Location | |||||||||
| Address1: | 11370 ANDERSON ST | ||||||||
| Address2: | STE 3150 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20A7972 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX79720 | 05 | CA | MEDICAID |