Provider Demographics
NPI:1437732427
Name:KEVIN CONCANNON LLC
Entity Type:Organization
Organization Name:KEVIN CONCANNON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:HAGAN
Authorized Official - Last Name:CONCANNON
Authorized Official - Suffix:II
Authorized Official - Credentials:CEO
Authorized Official - Phone:480-939-4656
Mailing Address - Street 1:15455 N GREENWAY HAYDEN LOOP STE C16
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1886
Mailing Address - Country:US
Mailing Address - Phone:480-939-4656
Mailing Address - Fax:480-524-1070
Practice Address - Street 1:15455 N GREENWAY HAYDEN LOOP STE C16
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1886
Practice Address - Country:US
Practice Address - Phone:480-939-4656
Practice Address - Fax:480-524-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03D2098042OtherCLIA