Provider Demographics
NPI:1821177031
Name:CHAN MEDICAL GROUP
Entity Type:Organization
Organization Name:CHAN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAN
Authorized Official - Middle Name:HOR
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-826-4771
Mailing Address - Street 1:600 W I ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3460
Mailing Address - Country:US
Mailing Address - Phone:209-826-4771
Mailing Address - Fax:209-826-8565
Practice Address - Street 1:600 W I ST
Practice Address - Street 2:SUITE C
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3460
Practice Address - Country:US
Practice Address - Phone:209-826-4771
Practice Address - Fax:209-826-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA257340174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76229ZMedicaid
CA=========OtherTAX-ID