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General NPI Number Information
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NPI Number | 1538166525
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Entity Type | Individual
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Provider Name | SANG CHAE KWAK P.T.
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Gender | Male
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Dates
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Enumeration Date | 07/05/2005
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Last Update Date | 08/12/2014
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Provider Practice Location Address
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Address Line | 12665 GARDEN GROVE BLVD SUITE 707
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City | GARDEN GROVE
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State | CA
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Zip | 92843-1901
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Country | US
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Telephone | 714-537-1234
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Fax | 714-537-3256
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Provider Business Mailing Address
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Address Line | 12665 GARDEN GROVE BLVD SUITE 707
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City | GARDEN GROVE
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State | CA
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Zip | 92843-1901
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Country | US
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Telephone | 714-537-1234
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Fax | 714-537-3256
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT30257
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License Number State | CA
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