Healthcare Provider Details

I. General information

NPI: 1073522314
Provider Name (Legal Business Name): KENNETH W. CHIN, M.D., INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16311 VENTURA BLVD SUITE120
ENCINO CA
91436-2124
US

IV. Provider business mailing address

16311 VENTURA BLVD SUITE120
ENCINO CA
91436-2124
US

V. Phone/Fax

Practice location:
  • Phone: 818-817-7707
  • Fax: 818-817-7727
Mailing address:
  • Phone: 818-817-7707
  • Fax: 818-817-7727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG29660
License Number StateCA

VIII. Authorized Official

Name: KENNETH W CHIN
Title or Position: OWNER
Credential: M.D.
Phone: 818-705-0745