Provider Demographics
NPI:1033627591
Name:KKMMCB MEDICAL, PLLC
Entity Type:Organization
Organization Name:KKMMCB MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDMS NPI COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LIZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-598-2800
Mailing Address - Street 1:1338 S FOOTHILL DR #331
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2321
Mailing Address - Country:US
Mailing Address - Phone:385-254-0279
Mailing Address - Fax:
Practice Address - Street 1:9980 SOUTH 300 WEST SUITE 200
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070
Practice Address - Country:US
Practice Address - Phone:385-254-0279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty