Provider Demographics
NPI:1902910235
Name:YI, KWON CHAE (CERTIFIED PROSTHETIS)
Entity Type:Individual
Prefix:MR
First Name:KWON
Middle Name:CHAE
Last Name:YI
Suffix:
Gender:M
Credentials:CERTIFIED PROSTHETIS
Other - Prefix:MR
Other - First Name:KWON
Other - Middle Name:JAE
Other - Last Name:YI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERTIFIED PROSTHETIS
Mailing Address - Street 1:2550 BEVERLY BOULEVARD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1035
Mailing Address - Country:US
Mailing Address - Phone:213-388-5847
Mailing Address - Fax:213-388-5848
Practice Address - Street 1:2550 BEVERLY BOULEVARD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1035
Practice Address - Country:US
Practice Address - Phone:213-388-5847
Practice Address - Fax:213-388-5848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ655562OtherBLUE SHIELD OF CALIFORNIA
CAXB0023570Medicaid
CA4491570001Medicare ID - Type Unspecified