=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700491990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSIGHT CHOICES COMMUNITY WELLNESS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2020
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8265 W SUNSET BLVD STE 207
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-375-0950
-----------------------------------------------------
Fax | 323-238-9581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8265 W SUNSET BLVD STE 207
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-375-0950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | ROBERT CHANG
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 323-375-0950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------