MEDICARE: KANG EASTERN MEDICINE INC

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	261QH0100X	Health Service Clinic/Center	AC-14622	CA

General Provider Information

NPI Number	:	1083966618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANG EASTERN MEDICINE INC

Provider Business Mailing Address
First Line	:	825 CHEHALEM RD
Second Line	:
City	:	LA CANADA
State	:	CA
Zip	:	91011-2502
Country	:	US
Telephone Number	:	818-864-6488
Fax Number	:	818-864-6488

Provider Business Practice Location Address
First Line	:	525 E COLORADO BLVD
Second Line	:	PENTHOUSE
City	:	PASADENA
State	:	CA
Zip	:	91101-5226
Country	:	US
Telephone Number	:	818-807-8849
Fax Number	:	626-389-5479

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MYEONGAE MISCHA KANG
Credential	:	LAC, DAOM
Telephone Number	:	818-807-8849

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	10/15/2012

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