Provider Demographics
NPI:1902394737
Name:KELKER MANAGEMENT CORP
Entity Type:Organization
Organization Name:KELKER MANAGEMENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TARIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:KELKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-330-1844
Mailing Address - Street 1:PO BOX 17062
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92817-7062
Mailing Address - Country:US
Mailing Address - Phone:714-330-1844
Mailing Address - Fax:
Practice Address - Street 1:160 E ARTESIA ST STE 310
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2922
Practice Address - Country:US
Practice Address - Phone:174-330-1844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125913208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA125913OtherMEDICAL LICENSE