Provider Demographics
NPI:1285927897
Name:KIM-WAYNE MEDICAL ENTERPRISES INC
Entity type:Organization
Organization Name:KIM-WAYNE MEDICAL ENTERPRISES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:KIM-WAYNBE
Authorized Official - Last Name:GIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-696-9078
Mailing Address - Street 1:218 W BADILLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1906
Mailing Address - Country:US
Mailing Address - Phone:626-332-6234
Mailing Address - Fax:626-331-1264
Practice Address - Street 1:218 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1906
Practice Address - Country:US
Practice Address - Phone:626-332-6234
Practice Address - Fax:626-331-1264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty