Provider Demographics
NPI:1730552845
Name:KPG OREGON, LLC
Entity type:Organization
Organization Name:KPG OREGON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-975-1450
Mailing Address - Street 1:9000 SUNSET BLVD #1500
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069
Mailing Address - Country:US
Mailing Address - Phone:310-975-1428
Mailing Address - Fax:
Practice Address - Street 1:486 12TH STREET #200
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103
Practice Address - Country:US
Practice Address - Phone:310-975-1428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-11
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD168198207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty