Provider Demographics
NPI:1750364345
Name:KAN-DI-KI LLC
Entity type:Organization
Organization Name:KAN-DI-KI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:930 RIDGEBROOK RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9481
Mailing Address - Country:US
Mailing Address - Phone:800-786-8015
Mailing Address - Fax:410-472-1754
Practice Address - Street 1:12612 RAYMER ST
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-4307
Practice Address - Country:US
Practice Address - Phone:818-549-1880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA205582291U00000X
291U00000X, 335V00000X
CA043518335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041261Medicaid
LA2443518Medicaid
TX414224201Medicaid
CAZZZ31268ZMedicaid
CA05D0679751OtherCLIA NUMBER
CALAB79751FMedicaid
CAZZZ59811ZMedicaid
OR500621162Medicaid
MN1750364345Medicaid
CAXR059811FMedicaid