MEDICARE: CHAD KIYOSHI EBESUTANI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	H00715964	HI

General Provider Information

NPI Number	:	1215186556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD KIYOSHI EBESUTANI

Provider Business Mailing Address
First Line	:	PO BOX 951563
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1563
Country	:	US
Telephone Number	:	310-825-3301
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 VETERAN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-2704
Country	:	US
Telephone Number	:	310-825-3301
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	10/02/2009

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