Healthcare Provider Details

I. General information

NPI: 1841725686
Provider Name (Legal Business Name): KAI EN TANG D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 03/06/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 HILLHURST AVE
LOS ANGELES CA
90027-5516
US

IV. Provider business mailing address

1025 PENNOCK PLACE FAMILY MEDICINE CENTER
FORT COLLINS CO
80524
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-3880
  • Fax: 323-660-0935
Mailing address:
  • Phone: 858-926-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: