Provider Demographics
NPI:1780015677
Name:KALLINI, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KALLINI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12390 AVENUE 29 SUITE 5
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-9999
Mailing Address - Country:US
Mailing Address - Phone:209-232-1290
Mailing Address - Fax:
Practice Address - Street 1:1201 CAMPBELL BOULEVARD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA - CALIFORNIA
Practice Address - Zip Code:95334
Practice Address - Country:UM
Practice Address - Phone:209-232-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018469172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY018469-1OtherLICENSE#