Provider Demographics
NPI:1730469974
Name:SOUTHERN CALIFORNIA ALLERGY
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA ALLERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-732-2774
Mailing Address - Street 1:303 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-5246
Mailing Address - Country:US
Mailing Address - Phone:512-732-2774
Mailing Address - Fax:
Practice Address - Street 1:16542 VENTURA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5045
Practice Address - Country:US
Practice Address - Phone:818-990-9155
Practice Address - Fax:818-990-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty