1083966618 NPI number — KANG EASTERN MEDICINE INC

Table of content: MS. LAURIE STEWART MEHALIC N.P. (NPI 1730260266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083966618 NPI number — KANG EASTERN MEDICINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KANG EASTERN MEDICINE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083966618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 CHEHALEM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CANADA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91011-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-864-6488
Provider Business Mailing Address Fax Number:
818-864-6488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 E COLORADO BLVD
Provider Second Line Business Practice Location Address:
PENTHOUSE
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91101-5226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-807-8849
Provider Business Practice Location Address Fax Number:
626-389-5479
Provider Enumeration Date:
10/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KANG
Authorized Official First Name:
MYEONGAE
Authorized Official Middle Name:
MISCHA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-807-8849

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  AC-14622 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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