Healthcare Provider Details

I. General information

NPI: 1740831908
Provider Name (Legal Business Name): KOA CAPITAL LTD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9665 WILSHIRE BLVD STE 450
BEVERLY HILLS CA
90212-2446
US

IV. Provider business mailing address

5061 HASKELL AVE
ENCINO CA
91436-1548
US

V. Phone/Fax

Practice location:
  • Phone: 310-247-8414
  • Fax: 310-247-9414
Mailing address:
  • Phone: 310-968-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AMANDA VAN DYK
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 310-968-2800