Healthcare Provider Details

I. General information

NPI: 1588029771
Provider Name (Legal Business Name): 123 MEDICAL GROUP CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 AMAR RD STE C12
WALNUT CA
91789-4561
US

IV. Provider business mailing address

18800 AMAR RD STE C12
WALNUT CA
91789-4561
US

V. Phone/Fax

Practice location:
  • Phone: 626-788-9691
  • Fax: 626-608-0318
Mailing address:
  • Phone: 626-788-9691
  • Fax: 626-608-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALLAN C CHANG
Title or Position: PRESIDENT
Credential: LAC, DOM, DAOM
Phone: 626-889-6917