Provider Demographics
NPI:1538166525
Name:KWAK, SANG CHAE (PT)
Entity type:Individual
Prefix:MR
First Name:SANG CHAE
Middle Name:
Last Name:KWAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:SANG
Other - Middle Name:
Other - Last Name:KWAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:12665 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 707
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1901
Mailing Address - Country:US
Mailing Address - Phone:714-537-1234
Mailing Address - Fax:714-537-3256
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 707
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1901
Practice Address - Country:US
Practice Address - Phone:714-537-1234
Practice Address - Fax:714-537-3256
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT30257AMedicare ID - Type UnspecifiedPHYSICAL THERAPIST
CAWPT30257BMedicare PIN