Provider Demographics
NPI:1164999090
Name:ANG, KERK EDWARD C
Entity Type:Individual
Prefix:
First Name:KERK EDWARD
Middle Name:C
Last Name:ANG
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 1:2508 SWEETWATER RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3236
Mailing Address - Country:US
Mailing Address - Phone:619-386-1299
Mailing Address - Fax:
Practice Address - Street 1:9920 PACIFIC HEIGHTS BLVD STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4361
Practice Address - Country:US
Practice Address - Phone:408-499-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA93837282FMedicaid