| Keen Medical Group, Inc. | |
|
12021 Jacaranda Ave Hesperia CA 92345-4978 | |
| (760) 956-5057 | |
| (760) 948-2179 |
| Full Name | Keen Medical Group, Inc. |
|---|---|
| Speciality | Family Medicine |
| Location | 12021 Jacaranda Ave, Hesperia, California |
| Authorized Official Name and Position | Arlene Braham (PRESIDENT) |
| Authorized Official Contact | 7609565057 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Keen Medical Group, Inc. 12021 Jacaranda Ave Hesperia CA 92345-4978 Ph: (760) 956-5057 | Keen Medical Group, Inc. 12021 Jacaranda Ave Hesperia CA 92345-4978 Ph: (760) 956-5057 |
| NPI Number | 1053456962 |
|---|---|
| Provider Enumeration Date | 02/20/2007 |
| Last Update Date | 03/03/2011 |
| Medicare PECOS PAC ID | 9537195144 |
|---|---|
| Medicare Enrollment ID | O20050714001024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053456962 | NPI | - | NPPES |
| GR0092540 | Medicaid | CA | |
| ZZZ64052Z | Other | CA | BLUE SHIELD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | G66379 (California) | Primary |
| Provider Name | Samuel George Wilson |
|---|---|
| Provider Type | Practitioner - Emergency Medicine |
| Provider Identifiers | NPI Number: 1912948019 PECOS PAC ID: 6103958319 Enrollment ID: I20100722000772 |
| Provider Name | Tracy Ann Dawes |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1609315746 PECOS PAC ID: 7214214915 Enrollment ID: I20170505002058 |
| Provider Name | Blaise Njieya Djeugoue |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1275086753 PECOS PAC ID: 3971872953 Enrollment ID: I20170706002970 |
| Provider Name | Audrey Y Reid |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1922166297 PECOS PAC ID: 5193143501 Enrollment ID: I20200917000903 |
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