=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891202263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD K. PANG MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2018
-----------------------------------------------------
Last Update Date | 01/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 S SAN VICENTE BLVD STE 901
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-860-3450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 69663
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-0663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EDWARD PANG
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 310-860-3450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 20A12433
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------