Provider Demographics
NPI:1396261582
Name:KENLEY EMERGENCY MEDICINE CORPORATION
Entity type:Organization
Organization Name:KENLEY EMERGENCY MEDICINE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:S
Authorized Official - Last Name:KENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-632-7244
Mailing Address - Street 1:100 N WIGET LN STE 200
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-5901
Mailing Address - Country:US
Mailing Address - Phone:773-632-7244
Mailing Address - Fax:
Practice Address - Street 1:100 N WIGET LN STE 200
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-5901
Practice Address - Country:US
Practice Address - Phone:773-632-7244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100640261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194847475Medicaid