MEDICARE: MR. SANG CHAE KWAK P.T.

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	225100000X	Physical Therapist	PT30257	CA

General Provider Information

NPI Number	:	1538166525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SANG CHAE KWAK P.T.

Provider Business Mailing Address
First Line	:	12665 GARDEN GROVE BLVD
Second Line	:	SUITE 707
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1901
Country	:	US
Telephone Number	:	714-537-1234
Fax Number	:	714-537-3256

Provider Business Practice Location Address
First Line	:	12665 GARDEN GROVE BLVD
Second Line	:	SUITE 707
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1901
Country	:	US
Telephone Number	:	714-537-1234
Fax Number	:	714-537-3256

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

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	08/12/2014

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