Healthcare Provider Details

I. General information

NPI: 1174263354
Provider Name (Legal Business Name): CASEY CHUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26001 REDLANDS BLVD
REDLANDS CA
92373-7762
US

IV. Provider business mailing address

11273 TERRA VISTA PKWY APT D
RANCHO CUCAMONGA CA
91730-7417
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: