Provider Demographics
NPI:1013135201
Name:KHEMARA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:KHEMARA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KITTYA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-218-5350
Mailing Address - Street 1:1533 ALAMITOS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-2214
Mailing Address - Country:US
Mailing Address - Phone:562-218-5350
Mailing Address - Fax:562-218-1630
Practice Address - Street 1:1533 ALAMITOS AVE STE B
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-2214
Practice Address - Country:US
Practice Address - Phone:562-218-5350
Practice Address - Fax:562-218-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79550174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16453Medicare ID - Type UnspecifiedPROVIDER NUMBER