Provider Demographics
NPI:1073859930
Name:KAN-DI-KI LLC
Entity Type:Organization
Organization Name:KAN-DI-KI LLC
Other - Org Name:DIAGNOSTIC LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CUOMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-786-8015
Mailing Address - Street 1:930 RIDGEBROOK RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9481
Mailing Address - Country:US
Mailing Address - Phone:800-786-8015
Mailing Address - Fax:
Practice Address - Street 1:7355 PRAIRIE FALCON RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0801
Practice Address - Country:US
Practice Address - Phone:702-982-0533
Practice Address - Fax:702-982-0991
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENTUSA HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-21
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5562LIC-4291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1073859930Medicaid
NVP01138750OtherRAILROAD MEDICARE
NV1073859930Medicaid