Provider Demographics
NPI:1396037206
Name:KC MEDICAL ENTERPRISE PLLC
Entity Type:Organization
Organization Name:KC MEDICAL ENTERPRISE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANGA-SIAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-992-3130
Mailing Address - Street 1:415 SOUTH MEDICAL DR STE C201
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4946
Mailing Address - Country:US
Mailing Address - Phone:801-992-3130
Mailing Address - Fax:801-992-3146
Practice Address - Street 1:415 SOUTH MEDICAL DR STE C201
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4946
Practice Address - Country:US
Practice Address - Phone:801-298-2332
Practice Address - Fax:801-298-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7430003-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000074194Medicare PIN
UTH30376Medicare UPIN
UTU000074195Medicare PIN