Provider Demographics
NPI:1811974363
Name:KTST, INC.
Entity type:Organization
Organization Name:KTST, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANSOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:TAFRESHI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-534-1100
Mailing Address - Street 1:12832 GARDEN GROVE BLVD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843
Mailing Address - Country:US
Mailing Address - Phone:714-534-1100
Mailing Address - Fax:714-534-1140
Practice Address - Street 1:12832 GARDEN GROVE BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843
Practice Address - Country:US
Practice Address - Phone:714-534-1100
Practice Address - Fax:714-534-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13590261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18087Medicare PIN