Healthcare Provider Details

I. General information

NPI: 1134397870
Provider Name (Legal Business Name): KENNY CHANG PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILSHIRE BLVD STE 745
LOS ANGELES CA
90025-1206
US

IV. Provider business mailing address

12021 WILSHIRE BLVD STE 745
LOS ANGELES CA
90025-1206
US

V. Phone/Fax

Practice location:
  • Phone: 310-348-1900
  • Fax:
Mailing address:
  • Phone: 310-348-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberPA16068
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: