MEDICARE: KIMMY PHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	19050	CA

General Provider Information

NPI Number	:	1043843816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMMY PHAN

Provider Business Mailing Address
First Line	:	11911 WEST ST
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-2552
Country	:	US
Telephone Number	:	714-467-9816
Fax Number	:

Provider Business Practice Location Address
First Line	:	11911 WEST ST
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-2552
Country	:	US
Telephone Number	:	714-467-9816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	11/01/2021

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Directions to “ KIMMY PHAN ” Practice Location

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