Provider Demographics
NPI:1174102693
Name:CHENG, KEVIN (PTA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:CHENG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16433 WOODRUFF AVE APT 35
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-4958
Mailing Address - Country:US
Mailing Address - Phone:646-864-9440
Mailing Address - Fax:
Practice Address - Street 1:9764 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1615
Practice Address - Country:US
Practice Address - Phone:714-624-5941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50932225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant