Healthcare Provider Details

I. General information

NPI: 1033457270
Provider Name (Legal Business Name): CHANA IVY CHANTAWANSRI CHIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 SUNSET BOULEVARD #83 150
LOS ANGELES CA
90027
US

IV. Provider business mailing address

4550 COLDWATER CANYON 204
STUDIO CITY CA
91604
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2120
  • Fax:
Mailing address:
  • Phone: 818-383-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA112215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: