Provider Demographics
NPI:1588029771
Name:123 MEDICAL GROUP CORP.
Entity Type:Organization
Organization Name:123 MEDICAL GROUP CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DOM, DAOM
Authorized Official - Phone:626-889-6917
Mailing Address - Street 1:18800 AMAR RD STE C12
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4561
Mailing Address - Country:US
Mailing Address - Phone:626-788-9691
Mailing Address - Fax:626-608-0318
Practice Address - Street 1:18800 AMAR RD STE C12
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-4561
Practice Address - Country:US
Practice Address - Phone:626-788-9691
Practice Address - Fax:626-608-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-15
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588029771OtherFAMILY MEDICINE