=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689860843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARL C. CHEN, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 11/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 W BASTANCHURY RD SUITE 140
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-773-0111
-----------------------------------------------------
Fax | 714-773-5518
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 W BASTANCHURY RD SUITE 140
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-773-0111
-----------------------------------------------------
Fax | 714-773-5518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CARL C. CHEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-773-0111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A30781
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------