Provider Demographics
NPI:1003924697
Name:SANG KWAK PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:SANG KWAK PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SANG CHAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:714-537-1234
Mailing Address - Street 1:12665 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 707
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1921
Mailing Address - Country:US
Mailing Address - Phone:714-537-1234
Mailing Address - Fax:714-537-3256
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 707
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1921
Practice Address - Country:US
Practice Address - Phone:714-537-1234
Practice Address - Fax:714-537-3256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3332040Medicaid
CA3332040Medicaid