Healthcare Provider Details

I. General information

NPI: 1902910235
Provider Name (Legal Business Name): KWON CHAE YI CERTIFIED PROSTHETIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KWON JAE YI CERTIFIED PROSTHETIS

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 BEVERLY BOULEVARD SUITE 201
LOS ANGELES CA
90057-1035
US

IV. Provider business mailing address

2550 BEVERLY BOULEVARD SUITE 201
LOS ANGELES CA
90057-1035
US

V. Phone/Fax

Practice location:
  • Phone: 213-388-5847
  • Fax: 213-388-5848
Mailing address:
  • Phone: 213-388-5847
  • Fax: 213-388-5848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: