Provider Demographics
NPI:1568744886
Name:KAN DI KI, LLC
Entity Type:Organization
Organization Name:KAN DI KI, LLC
Other - Org Name:DIAGNOSTIC LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CUOMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:007-868-0158
Mailing Address - Street 1:2820 N. ONTARIO STREET
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2015
Mailing Address - Country:US
Mailing Address - Phone:818-549-1880
Mailing Address - Fax:818-333-7186
Practice Address - Street 1:3418 MIDCOURT RD STE 105
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-4944
Practice Address - Country:US
Practice Address - Phone:972-468-3581
Practice Address - Fax:443-842-7264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2028785291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2443461Medicaid
TXP01099732OtherRAILROAD MEDICARE
TX414224201Medicaid