Provider Demographics
NPI:1225471956
Name:MLT KIDANE PHYSICIAN ASSISTANT CORPORATION
Entity Type:Organization
Organization Name:MLT KIDANE PHYSICIAN ASSISTANT CORPORATION
Other - Org Name:MED-HANIT ALEM MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MEAZA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:KIDANE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:951-571-0632
Mailing Address - Street 1:12981 PERRIS BLVD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4102
Mailing Address - Country:US
Mailing Address - Phone:951-571-0632
Mailing Address - Fax:951-571-4149
Practice Address - Street 1:12981 PERRIS BLVD
Practice Address - Street 2:SUITE #101
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4102
Practice Address - Country:US
Practice Address - Phone:951-571-0632
Practice Address - Fax:951-571-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20768363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty