Provider Demographics
NPI:1174104186
Name:PHAN, KENNY H (CRT)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:H
Last Name:PHAN
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13071 BROOKHURST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5514
Mailing Address - Country:US
Mailing Address - Phone:714-425-9066
Mailing Address - Fax:
Practice Address - Street 1:13071 BROOKHURST ST STE 100
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-5514
Practice Address - Country:US
Practice Address - Phone:714-425-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27192471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging