Provider Demographics
NPI:1972533875
Name:KEN MIN CHAI PAK M.D.
Entity Type:Organization
Organization Name:KEN MIN CHAI PAK M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIN CHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-564-8457
Mailing Address - Street 1:315 S GRAND OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-5009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14540 VICTORY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1600
Practice Address - Country:US
Practice Address - Phone:818-989-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055770261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19413Medicare ID - Type Unspecified
CAG63402Medicare UPIN