Provider Demographics
NPI:1114399581
Name:SANGA, KENNETH JOHN PERALTA
Entity Type:Individual
Prefix:
First Name:KENNETH JOHN
Middle Name:PERALTA
Last Name:SANGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14659 OLIVE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1652
Mailing Address - Country:US
Mailing Address - Phone:818-485-0888
Mailing Address - Fax:818-833-5690
Practice Address - Street 1:14659 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1652
Practice Address - Country:US
Practice Address - Phone:818-485-0888
Practice Address - Fax:818-833-5690
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36258167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician