Provider Demographics
NPI:1205860525
Name:K.C. MEDICAL CORPORATION
Entity Type:Organization
Organization Name:K.C. MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-303-4651
Mailing Address - Street 1:1755 HUNTINGTON DR
Mailing Address - Street 2:#104
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2567
Mailing Address - Country:US
Mailing Address - Phone:626-303-4651
Mailing Address - Fax:626-358-0915
Practice Address - Street 1:1755 HUNTINGTON DR
Practice Address - Street 2:#104
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2567
Practice Address - Country:US
Practice Address - Phone:626-303-4651
Practice Address - Fax:626-358-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG45341AMedicare PIN
CAA49994Medicare UPIN