MEDICARE: KELLY CHANG RD

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	133V00000X	Registered Dietitian	86114201	CA

General Provider Information

NPI Number	:	1790335396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY CHANG RD

Provider Business Mailing Address
First Line	:	1829 WESTHOLME AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4946
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2716 OCEAN PARK BLVD STE 3020
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-5225
Country	:	US
Telephone Number	:	310-829-9161
Fax Number	:

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

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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Directions to “ KELLY CHANG RD” Practice Location

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