Provider Demographics
NPI:1598956997
Name:KENNETH RICH MD
Entity Type:Organization
Organization Name:KENNETH RICH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-583-6052
Mailing Address - Street 1:2640 ZOE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4132
Mailing Address - Country:US
Mailing Address - Phone:323-583-6052
Mailing Address - Fax:323-589-3729
Practice Address - Street 1:2640 ZOE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4132
Practice Address - Country:US
Practice Address - Phone:323-583-6052
Practice Address - Fax:323-589-3729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50272208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A502720Medicaid
CA00A502720Medicaid