Provider Demographics
NPI:1104382506
Name:KAMOTHO, ELIJAH KIHARA
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:KIHARA
Last Name:KAMOTHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30362 BLUE CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-2744
Mailing Address - Country:US
Mailing Address - Phone:714-452-4439
Mailing Address - Fax:
Practice Address - Street 1:30362 BLUE CEDAR DR
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-2744
Practice Address - Country:US
Practice Address - Phone:714-452-4439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN283551164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse