Provider Demographics
NPI:1295184810
Name:PHAN, KENNY
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:PHAN
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 1:9702 BOLSA AVE SPC 66
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6640
Mailing Address - Country:US
Mailing Address - Phone:858-357-4617
Mailing Address - Fax:
Practice Address - Street 1:9702 BOLSA AVE SPC 66
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6640
Practice Address - Country:US
Practice Address - Phone:858-357-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11701171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist