Healthcare Provider Details

I. General information

NPI: 1699232454
Provider Name (Legal Business Name): KWANG HE WON HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S. ARDMORE AVE 1ST FLOOR
LOS ANGELES CA
90005-2597
US

IV. Provider business mailing address

815 S. ARDMORE AVE 1ST FLOOR
LOS ANGELES CA
90005-2597
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-0448
  • Fax: 213-260-8268
Mailing address:
  • Phone: 213-385-0448
  • Fax: 213-260-8268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BONGJA BENA WON
Title or Position: CEO/PRESIDENT
Credential: MD
Phone: 213-385-0448