Healthcare Provider Details

I. General information

NPI: 1780112581
Provider Name (Legal Business Name): MICHELLE CHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N SEPULVEDA BLVD STE 210
MANHATTAN BEACH CA
90266
US

IV. Provider business mailing address

111 N SEPULVEDA BLVD STE 210
MANHATTAN BEACH CA
90266-6849
US

V. Phone/Fax

Practice location:
  • Phone: 310-379-2134
  • Fax:
Mailing address:
  • Phone: 310-379-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: