Provider Demographics
NPI:1083926612
Name:KAN-DI-KI LLC
Entity Type:Organization
Organization Name:KAN-DI-KI LLC
Other - Org Name:TRIDENTCARE
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
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 1:17744 NE SAN RAFAEL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5927
Practice Address - Country:US
Practice Address - Phone:800-638-3240
Practice Address - Fax:303-576-7986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500654573Medicaid
ORP01099725OtherRAILROAD MEDICARE
ORP01099725OtherRAILROAD MEDICARE