Provider Demographics
NPI:1053456962
Name:KEEN MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:KEEN MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-956-5057
Mailing Address - Street 1:12021 JACARANDA AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4978
Mailing Address - Country:US
Mailing Address - Phone:760-956-5057
Mailing Address - Fax:760-948-2129
Practice Address - Street 1:12021 JACARANDA AVE
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4978
Practice Address - Country:US
Practice Address - Phone:760-956-5057
Practice Address - Fax:760-948-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0092540Medicaid
CAZZZ64052ZOtherBLUE SHIELD
CAZZZ23597ZMedicare ID - Type Unspecified