Healthcare Provider Details

I. General information

NPI: 1023205010
Provider Name (Legal Business Name): JIMMY C. HUANG, D.O. A PROFESSIONAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 SANTA MONICA BLVD. SUITE C
SANTA MONICA CA
90404
US

IV. Provider business mailing address

1158 26TH STREET SUITE 570
SANTA MONICA CA
90403
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-1708
  • Fax: 310-828-1705
Mailing address:
  • Phone: 310-453-3668
  • Fax: 310-453-3634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A6713
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JIMMY C. HUANG
Title or Position: CEO
Credential: D.O.
Phone: 323-292-0211