Provider Demographics
NPI:1376346494
Name:TA, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8310 REGENTS RD UNIT 2G
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1345
Mailing Address - Country:US
Mailing Address - Phone:626-280-4300
Mailing Address - Fax:
Practice Address - Street 1:101 N BRAND BLVD STE 604
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2615
Practice Address - Country:US
Practice Address - Phone:866-701-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program