Provider Demographics
NPI:1417045238
Name:LEMI MEDICAL CENTER PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LEMI MEDICAL CENTER PROFESSIONAL CORPORATION
Other - Org Name:NANI KHANANASHVILI DBA LEMI MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-697-0361
Mailing Address - Street 1:1838 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3126
Mailing Address - Country:US
Mailing Address - Phone:650-697-0361
Mailing Address - Fax:650-697-8752
Practice Address - Street 1:1838 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3126
Practice Address - Country:US
Practice Address - Phone:650-697-0361
Practice Address - Fax:650-697-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77565207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2865505OtherCA STATE CORPORATE ID