Healthcare Provider Details

I. General information

NPI: 1013868249
Provider Name (Legal Business Name): KENNY PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11420 WARNER AVE
FOUNTAIN VALLEY CA
92708-2529
US

IV. Provider business mailing address

11420 WARNER AVE
FOUNTAIN VALLEY CA
92708-2529
US

V. Phone/Fax

Practice location:
  • Phone: 657-205-0455
  • Fax:
Mailing address:
  • Phone: 657-205-0455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: